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DELIRIUM & DEMENTIA
Dana Bartlett, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author.
His clinical experience includes 16 years of ICU
and ER experience and over 20 years of as a poison control center
information specialist. Dana has published numerous CE and journal articles,
written NCLEX material and textbook chapters, and done editing and
reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has
written widely on the subject of toxicology and was recently named a
contributing editor, toxicology section, for Critical Care Nurse journal. He is
currently employed at the Connecticut Poison Control Center and is actively
involved in lecturing and mentoring nurses, emergency medical residents and
pharmacy students.
ABSTRACT
There are many possible causes of dementia and delirium and the
more common ones are complex, such as dementia of the
Alzheimmer’s type or delirium due to drug withdrawal. This study
module will present general information about the patient with
dementia and delirium, including risk factors, treatments, and nursing
considerations. Two other relevant neurological problems, mild
cognitive impairment and pseudo-dementia, will be briefly discussed.
Detailed and extensive information about specific causes of these
diseases is outside the scope of this study.
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Continuing Nursing Education Course Director & Planners:
William A. Cook, PhD, Director; Douglas Lawrence, MS, Webmaster;
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Accreditation Statement:
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses.
Credit Designation:
This educational activity is credited for 3.5 hours. Pharmacology
content is 15 minutes. Nurses may only claim credit commensurate
with the credit awarded for completion of this course activity.
Course Author & Planner Disclosure Policy Statements:
It is the policy of NurseCe4Less.com to ensure objectivity,
transparency, and best practice in clinical education for all continuing
nursing education (CNE) activities. All authors and course planners
participating in the planning or implementation of a CNE activity are
expected to disclose to course participants any relevant conflict of
interest that may arise.
Statement of Need:
Nurses in all practice settings that care for individuals with dementia
and delirium need to understand what defines each disorder, and
diagnostic criteria related to etiology, clinical assessment and signs
and symptoms.
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Course Purpose:
To provide professional nurses with the information they need to
assess and care for patients with dementia or delirium.
Learning Objectives:
1. Identify the correct definition of dementia.
2. Identify the correct definition of delirium.
3. Identify differences between dementia and delirium.
4. Identify risk factors for dementia and delirium.
5. Identify common treatment options for dementia and delirium.
Target Audience:
Advanced Practice Registered Nurses, Registered Nurses, Licensed
Practical Nurses and Nursing Associates
Course Author & Director Disclosures:
Dana Bartlett, RN, BSN, MA, MSN, William S. Cook, PhD,
Douglas Lawrence, MS, Susan DePasquale, CGRN, MSN, FPMHNP-BC -
all have no disclosures.
Acknowledgement of Commercial Support: There is none.
Activity Review Information:
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC.
Release Date: 10/11/2014 Termination Date: 10/11/2016
Please take time to complete the self-assessment Knowledge Questions
before reading the article. Opportunity to complete a self-assessment of
knowledge learned will be provided at the end of the course.
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1. One of the defining characteristics of dementia is:
a. inability to perform activities of daily living.
b. severe agitation.
c. reversible cognitive impairment.
d. occurrence before age 50.
2. Most cases of dementia are caused by:
a. trauma and heavy metal poisoning.
b. infections and hemorrhage.
c. Alzheimer’s disease and vascular pathologies.
d. hypoxia and Parkinson’s disease.
3. Defining characteristics of delirium include:
a. movement disorders and a progressive cognitive decline.
b. attention deficits and confusion.
c. expressive aphasia and hypotension.
d. hyperthermia and depression.
4. Common causes of delirium include:
a. Parkinson’s disease and advanced age.
b. drug withdrawal and Lewy body dementia.
c. acute blood loss and frontotemporal dementia
d. drugs and dementia.
5. True or false: Dementia is an inevitable consequence of
aging.
a. True.
b. False.
6. Dementia is often misdiagnosed as:
a. depression.
b. mild cognitive impairment.
c. Alzheimer’s disease.
d. anxiety.
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7. Use physical restraints with patients who have dementia or
delirium:
a. if the patient is agitated or confused.
b. when there is a significant risk for a fall.
c. if all other interventions fail and there is a serious risk of harm.
d. if the patient is likely to wander.
8. Neuropsychiatric behavior problems in patients who have
dementia:
a. are caused by an external or internal stimulus.
b. typically occur randomly and without cause.
c. only occur if patients are over-medicated.
d. happen primarily at night.
9. The use of anti-psychotics to treat patients with dementia:
a. is considered first-line therapy.
b. is most effective when used in conjunction with cholinesterase
inhibitors.
c. can reverse the progress of dementia.
d. is questionably effective and potentially dangerous
10. The drug most commonly used to treat agitation in patients
who have delirium is:
a. diazepam.
b. haloperidol.
c. galantamine.
d. bupropion.
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INTRODUCTION
Dementia and delirium are the major causes of cognitive impairment
in the elderly.1 Dementia and delirium are syndromes. A syndrome is
identified by a set of symptoms and/or signs that tend to be present in
a patient at the same time. A syndrome may be caused by one or
more diseases.
Dementia and delirium are caused by a wide range of medical,
neurological and psychiatric pathologies. In some cases a specific
etiology can be confirmed by laboratory testing, specific physical
findings, or imaging studies. Most often, dementia and delirium are
clinical diagnoses. Clinicians formulating a diagnostic impression need
to understand that the relationship between dementia and delirum is
complex. There are similarities in their presentation; dementia is a
major risk factor for delirium, and delirium occurs in many patients
who have dementia.
Delirium and dementia can be acute or sub-acute, and they can be
transient and reversible or can cause permanent impairment. Both are
associated with increased morbidity and mortality. The risk of
developing dementia and/or delirium increases with advancing age,
and as the population in the US becomes older the incidence of these
pathologies will certainly increase.
Statistics
Dementia and delirium are very common, as shown in the following
statistics:
Delirium is noted in 14%-56% of elderly patients who are
hospitalized and in 40% of patients admitted to intensive care.2
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Postoperative delirium is seen in approximately 5%-10% of
general surgery patients.2
Community-based studies have found a prevalence of dementia
as high as 47% in those 85 years of age and older.1
Alzheimer’s disease is the most common cause of dementia3 and
in 2013 there were approximately 5 million Americans who
suffered from Alzheimer’s disease.4
There are many causes of dementia but Alzheimer’s disease
accounts for approximately 60%-80% of all cases.5
Delirium occurs in approximately two-thirds of all adults living in
nursing homes.6
Slowing of cognitive function can occur with aging and it is not
uncommon for older people to have mild memory deficits or a
reduction in the speed with which information is processed. Old age is
a major risk factor for dementia, but advanced age itself does not
cause a decrease in cognitive and intellectual ability that interferes
with daily functioning. In brief, dementia is not an inevitable
consequence of getting old.
DEFINITION, DIAGNOSTIC CRITERIA, AND
CAUSES OF DEMENTIA
Dementia can be defined in several ways. Kane et al. (2013) defines
dementia as “. . . a clinical syndrome involving a sustained loss of
intellectual functions and memory of sufficient severity to cause
dysfunction in daily living,”1 while Seeley and Miller (2012) write that
dementia “. . . is an acquired deterioration in cognitive abilities that
impairs the successful performance of activities of daily living.”3 These
definitions emphasize key points about dementia to remember.
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Firstly, the distinguishing aspect of dementia is an inability to
successfully perform the activities of daily living, caused by impaired
cognitive and intellectual capacity. Secondly, dementia is a syndrome
because there is a multitude of etiologies of dementia. Because there
is no single cause of dementia the clinical picture can be variable. The
Diagnostic and Statistical Manual of Mental Disorders V (DSM-V)
criteria for dementia, which is called major neurocognitive disorder,
are:7
A. Evidence of significant cognitive decline from a previous level of
performance in one or more cognitive domains:
Complex attention
Executive function
Language
Learning and memory
Perceptual-motor ability
Social cognition
B. The cognitive effects interfere with independence in everyday
activities. At a minimum, assistance should be required with
complex activities of daily living such as managing medications
or paying bills.
C. The cognitive effects do not occur extensively in the context of
delirium.
D. The cognitive deficits are not better explained by another mental
disorder (i.e., major depressive disorder, schizophrenia).
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Dementia can be usefully divided into two categories: reversible and
irreversible. Most cases of dementia are irreversible. These dementias
slowly progress and the patient’s condition worsens over time.
Irreversible dementias are caused by: degenerative diseases of the
nervous system, infections, trauma, and vascular disorders. The most
common irreversible dementias are Alzheimer’s disease,
frontotemporal dementia, Lewy body dementia, Parkinson’s disease,
and vascular dementia. Many patients who have dementia have a
neurodegenerative and a vascular pathology.8
Table 1: Irreversible causes of dementia1
Acquired immunodeficiency syndrome
Alzheimer disease
Anoxia secondary to cardiac arrest
Arteritis
Binswanger disease
Carbon monoxide poisoning
Cerebrovascular disease, i.e., multi-infarct dementia
Craniocerebral injury, including dementia pugilistica
Creutzfeldt-Jakob disease
Huntington’s disease
Dementia associated with Lewy bodies
Frontotemporal dementia
Infections
Parkinson’s disease
Pick disease
Postencephalitic dementia
Progressive multifocal leukoencephalopathy
Progressive supranuclear palsy
Trauma
Vascular dementias
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The reversible dementias are much less common than the irreversible
dementias. Irreversible dementias can be successfully treated but
finding and treating the cause does not guarantee a cure.
Table 2: Reversible or partially reversible causes of dementia1
Alcoholism
Anoxic brain injury
Autoimmune disorders
Central nervus system vasculitis
Disseminated lupus erythematous
Depression
Drugs
Heavy metal poisoning, i.e., lead, mercury
Infections
Metabolic disorders
Multiple sclerosis
Neoplasms
Normal pressure hydrocepahlus
Nutritional disorders, i.e., B6, B12 deficiency
Organic poisons, i.e., pesticides, solvents
Psychiatric disorders
Trauma
Viral infections, i.e., HIV
Medications, prescription or illicit, can also cause dementia. In most
cases the dementia caused by a drug is reversible but not always.
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Table 3: Drugs that can cause dementia and delirium 1
Alcohol
Analgesics
Antiarrhythmics
Anticholinergic agents
Anticonvulsants
Antidepressants
Antihypertensives
Antipsychotics
Anxiolytics
Digoxin
H2 receptor antagonists
Non-steroidal antiiflammatories
Sedative-hypnotics
Skeletal muscle relaxers
Steroids
There is a wide range of causes of dementia, but there are similarities
in their clinical presentation.
Irreversible dementia is typically progressive, the signs and
symptoms worsening over a course of months and years. The
course is individualized with no predictability as to its pattern.
There is no usual disturbance of consciousness: the patient is
awake, alert, and responsive.
Memory loss is the most prominent cognitive disability of
dementia.
Impairment of language, visuospatial ability, calculation,
judgment, and problem solving are also common in patients who
have dementia.
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Patients who have dementia often suffer from neuropsychiatric
problems including, but not limited to, agitation, apathy,
delusions, depression, disinhibition, hallucinations, insomnia, and
wandering.
As mentioned previously, the most common causes of irreversible
dementia are Alzheimer’s disease, frontotemporal dementia, Lewy body
dementia, Parkinson’s disease, and vascular dementia. Some of these
may not be familiar to many nurses and a brief description of each one
is provided below.
Alzheimer’s disease
Alzheimer’s disease is a chronic, progressive neurological disorder that
causes severe behavioral and cognitive deterioration, especially in
memory. The cause, or causes, of Alzheimer’s disease are not
completely understood. Alzheimer’s disease is probably the result of a
convergence of genetic risk factors and environmental stimuli that
produce characteristic lesions in the parietal and temporal lobes,
specifically amyloid plaques and neurofibrillary tangles. These lesions
interrupt the normal metabolism and self-repair of neurons and disrupt
communication between different areas of the brain.
The time from diagnosis to death can be as little as three years. The
signs and symptoms of Alzheimer’s disease are difficult to treat and
there is no cure.
Frontotemporal lobe dementia
Frontotemporal lobe dementia is a neuro-degenerative disease caused
by atrophy of the frontal and temporal lobe. It is a disease that is
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considered clinically and genetically diverse. The hallmark signs of
frontotemporal dementia are behavioral and speech defects, such as
expressive and fluent aphasia and abnormal personal and social
behavior. In most cases the cause is unknown, however, a family
history of the disease is a strong risk factor. Frontotemporal dementia
is chronic, progressive, and there is no cure.
Lewy body dementia
Lewy body dementia is a chronic, progressive neurodegenerative
disease that is characterized by the presence of Lewy bodies,
abnormal deposits of protein that accumulate in neurons in specific
areas of the brain. The cause of Lewy body dementia is not known. It
is distinguished from other types of dementia by the Lewy bodies and
by these aspects of the clinical presentation:
1. varying levels of alertness and attention, especially reduced
responsiveness;
2. visual hallucinations, and;
3. Parkinsonian motor signs.
There appears to be some overlap of Lewy body dementia with
Alzheimer’s disease and Parkinson’s disease with dementia. Lewy
bodies are noted in some patients with Alzheimer’s disease (Lewy body
variant of Alzheimer’s disease) and in some patients with Parkinson’s
disease. Additionally, some of the signs of Parkinson’s disease with
dementia and Lewy body dementia are similar. There is no cure for
Lewy body dementia.
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Parkinson’s disease
Parkinson’s disease is caused by chronic and progressive destruction of
dopamine-producing cells in the substantia nigra area of the brain.
Parkinson’s disease often causes dementia, but it is distinguished by
characteristic motor symptoms such as bradykinesia (slowness of
movements), gait disturbances, rigidity, and tremor.
Approximately 10% of all cases of Parkinson’s can be clearly identified
as having a genetic cause, but most cases are considered to be caused
by a convergence of genetic risk factors and environmental stimuli.
There is no cure for Parkinson’s disease but there is effective
symptomatic treatment and the progression of the disease can be
delayed.
Vascular dementia
Vascular dementia is the second most common cause of dementia and
it often co-exists with Alzheimer’s disease. Vascular dementia is not a
single disease; it is a group of syndromes that are caused by vascular
pathologies, such as:
cerebral infarct
cerebral hemorrhage
embolic and/or thrombotic obstructions (i.e., stroke)
various types of lesions like lacunar lesions
There are many causes of vascular dementia, and atherosclerosis,
diabetes, hypercholesterolemia, hypertension, and smoking are
significant risk factors.
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DEFINITION, DIAGNOSTIC CRITERIA, AND
CAUSES OF DELIRIUM
Delirium is an acute change in mental status characterized by
confusion and attention deficits.2,9 As with dementia, delirium is a
syndrome, there are a multitude of causes, and the clinical
presentation can vary. Delirium is usually transient and reversible, but
delirium can persist for hours or days (acute) or weeks or months
(persistent), and it is associated with high rates of morbidity and
mortality.
The Fifth Edition of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-V) criteria for a diagnosis of delirium are:10
1. A disturbance in attention, i.e., reduced ability to direct, focus,
sustain, and shift attention and disturbance in awareness, i.e.,
reduced orientation to the environment.
2. The disturbance develops over a short period of time, usually
hours to a few days. It represents a change from baseline
attention and awareness, and tends to fluctuate in severity
during the course of a day.
3. An additional disturbance in cognition such as memory deficit,
disorientation, language, visuospatial ability, or perception.
4. The disturbances are not better explained by another
preexisting, established, or evolving neurocognitive disorder and
do not occur in the context of a severely reduced level of
arousal, such as coma.
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5. There is evidence from the history, physical examination, or
laboratory findings, that the disturbance is a direct
physiological consequence of another medical condition, such as,
substance intoxication, or withdrawal from a drug of abuse or to
a medication, exposure to a toxin, or due to multiple etiologies.
Delirium is a sudden change in cognition. It develops over a short
period and it fluctuates in severity; and the most prominent feature of
delirium is the change that occurs in attention and awareness. The
DSM-V and other sources note that delirium can be manifested by
hyperactive, hypoactive, or mixed states.
Hyperactive delirium is characterized by a hyperactive level of
psychomotor activity, and it is seen in patients who are intoxicated or
in withdrawal from drugs such as amphetamine or phencyclidine.
Hypoactive delirium is characterized by a decreased level of
psychomotor activity, and the patient is lethargic and sluggish.
Whereas, mixed state delirium is characterized by alternating periods
of agitation and sedation.
As with dementia, there are many causes of delirium that may
influence a patient’s health condition. Drugs and medications are an
important and common cause of delirium. Dementia is also a very
common cause of delirium. Delirium can happen to any patient, but it
is more common in the elderly. Causes of delirium are listed in Table 4
below.
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Table 4: Common causes of delirium1,11
Acute blood loss
Acute myocardial infarction
Acute psychoses
Azotemia
Congestive heart failure
Decreased cardiac output
Decreased sensory input
Dehydration
Dementia
Drugs
Drug overdose
Drug withdrawal
Dehydration
Fecal impaction
Intoxication
Hypercarbia
Hypo- or hyperglycemia
Hyponatremia
Hypo- or hyperthermia
Hypoxia
Infections
Metabolic disorders
Parkinson’s disease
Stroke (small cortical)
Urinary retention
It is not clear if advanced age itself is a risk factor for delirium.
However, the elderly patient population often has greater exposure to
identified risk factors for delirium: bladder catheterization, decreased
ability to metabolize and eliminate medications, dementia, fracture,
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hearing impairment, immobility, inadequate or excessive use of
analgesics or sedatives, malnutrition, multiple medications, pre-
existing dementia, sensory deprivation, status-post anesthesia and
surgery, underlying medical or neurologic illnesses, use of physical
restraints, and visual impairment.1,6,10
Delirium is often misdiagnosed2,10 and it may be mistaken for
dementia, depression, another psychiatric disorder, or attributed to
“old age.” This under-recognition can delay treatment, and it can also
prolong the duration of delirium and expose the patient to permanent
neurological damage.6
MILD COGNITIVE IMPAIRMENT AND PSEUDO-DEMENTIA
Mild cognitive impairment (MCI) and pseudo-dementia should also be
mentioned when discussing dementia. Individuals who have MCI or
pseudo-dementia can often develop dementia. MCI is often
overlooked; and, pseudo-dementia is often misdiagnosed as dementia.
Mild cognitive impairment is a term used to describe cognitive deficits
that are not considered to be a normal part of aging but do not fit the
diagnostic criteria for dementia.7,12 There are differences in the
diagnostic criteria for MCI and these criteria are not precise, but MCI is
generally considered to be an intermediate state between normal
cognitive functioning and dementia. Patients who have MCI have
memory deficits and occasionally they have subtle defects in other
cognitive abilities, but they have normal executive functioning and
they do not have difficulties performing activities of daily living.7,11,13
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The patient who has MCI is aware of the change in his or her memory,
unlike the person who has dementia. Mild cognitive impairment may
be temporary13 but approximately 15% of people who have MCI will
develop dementia.14
Pseudo-dementia is a descriptive term for a clinical presentation that
closely mimics dementia, but is usually caused by depression7 and
occasionally by other psychiatric disorders.15 Depression in the elderly
can cause many of the cognitive defects that are common to dementia.
Dementia can produce depressive signs and symptoms16 such that a
misdiagnosis is relatively common. Some key differences between
dementia and depression are:7
Depression has an abrupt onset but the onset of dementia is
slow.
Dementia progresses while depression plateaus.
Patients who are depressed often know they are depressed and
will complain of their problem. Patients who have dementia are
seldom aware of their condition.
The affect and emotions of people who have dementia are
variable. People who are depressed have a depressed affect and
mood.
Imaging tests, laboratory tests, and the neurological exam of a
patient who has dementia will often be abnormal; this is not the
case for patients who are depressed.
ASSESSMENT OF DEMENTIA
Assessment and the diagnosing of dementia can be quite challenging.
One of the primary problems in assessment is that the ptient is often
an unreliable source of information. Confirmation of the diagnosis of
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dementia using imaging studies, laboratory tests, and/or specific
physical findings may not be possible. Also, some patients may have
more than one cause of dementia. The diagnostic process is time
consuming, and it is not uncommon for dementia to be misdiagnosed.5
The incidence of a missed diagnosis of dementia has been reported to
be as high as 50%-80%, depending on the severity of the case and
who is doing the assessment.17 The specific diagnostic approach, i.e.,
what tests should be ordered, will differ depending on the suspected
cause of dementia. The assessment process outlined below can be
applied to any situation in which dementia may be present.
Vital signs
Assessment of the airway, breathing, and circulation (ABCs) and body
temperature is always the first step of a patient assessment.
Abnormalities of blood pressure, pulse, and temperature, etc., can
provide valuable indicators about the source of dementia. For example,
hypothermia can indicate the presence of hypothyroidism and
hypertension can indicate the presence of vascular dementia.
History
The events in the patient’s life prior to the assessment should be
reviewed, either by speaking to the patient, family members, friends,
or caretakers. The reviewer should ask specific questions about
behavior, changes in social circumstances, daily activities, elimination
patterns, food and fluid intake, and mood. It is important to learn
whether there have been any recent events such as an accident,
illness, trauma, or surgery that could be a cause of delirium.
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Family or significant other interview
A careful interview of family members or significant others and
caretakers are a necessary part of patient evaluation because the
patient who has dementia will seldom be aware of the changes in
cognition and memory. The interviewer should ask specific questions
about the patient’s day-to-day life:
Has the patient been agitated, disruptive, or verbally aggressive?
Has there been wandering behavior or dangerous driving?
Has the patient had difficulty wth sleeping?
Has the patient’s personal hygiene deteriorated or has he or she
been incontinent?
Galvin et al. (2006) found that the following eight question interview
was sensitive and specific for detecting dementia and cognitive
impairment.18 The following should be investigated: Has the patient
shown any of the following deficits or behaviors?
Problems with judgment
Reduced interest in activities or hobbies
Repeating questions, stories, or statements
Trouble learning how to use an appliance or tool
Forgetting what month or year it is
Unable to handle simple financial affairs
Forgetting appointments
Consistent problems with memory and/or thinking
Medical and surgical history
The patient’s medical and surgical history should be be carefully
reviewed. This review should include the medical history of the
patient’s immediate family, i.e., parents and siblings. Asking about
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alcohol or drug abuse can be uncomfortable but it should be done as
often times as is necessary. Additionally, it is often helpful to review
the patient’s history of alcohol or drug abuse with someone other than
the patient.
Medication history
When reviewing the patient’s health history, a current list of the
prescription medications the patient is taking should be obtained and
verified to know whether new medications have recently been
prescribed or doses have been changed. An inquiry should be made
about the use of over-the-counter and/or herbal medications. It should
also be determined if the patient has been taking his or her
medications as prescribed. There may have been an inadvertent or
intentional overdose, the patient may have been skipping doses, or he
or she may have simply stopped taking a prescribed medication.
Physical assessment
A comprehensive physical examination should be performed. The
findings may be equivocal and/or non-specific. But the presence of
some physical findings and the absence of others can help the
clinician decide which diagnostic tests should be done and suggest the
cause of the dementia. For example, bradykinesia and gait
disturbances are characteristic of Parkinson’s disease, the presence of
papilledema suggests that the patient may a brain tumor or a subdural
hematoma, and myoclonus can indicate the presence of human
immunodeficiency virus (HIV)-related dementia.8
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Laboratory tests, imaging studies, and other diagnostic tools
There are no laboratory tests, imaging studies, or other diagnostic
tools that should be routinely performed for every patient who is
suspected of having dementia.5 The physical examination and history
taking should determine what is needed, and it is important to focus
diagnostic efforts in order to avoid unnecessary procedures and delays
in making the diagnosis.
Laboratory tests that are helpful when determining the cause or
presence of dementia include complete blood count (CBC), blood urea
nitrogen (BUN) and creatinine, serum calcium and phosphorus, pulse
oximetry, serum glucose, serum electrolytes, liver function tests,
thyroid studies, vitamin B12 level, 12-lead ECG, and (possibly) testing
for HIV antibodies. The use of neuro-imaging studies such as
computerized tomography (CT) and magnetic resonance imaging
(MRI) can be used to determine the specific type of dementia, to
evaluate the progress of neurological damage, and possibly predict
who will develop dementia.19,20 For example, medial temporal lobe
atrophy is common in patients with dementia, but it is usually more
pronounced, and the pattern of injury different, in patients who have
Alzheimer’s disease; and, cerebral infarcts may be seen in patients
who have vascular dementia.19
DEMENTIA: NEUROLOGICAL AND PSYCHIATRIC EVALUATION
A careful assessment of the patient’s neurological and psychiatric
status is the crucial part of the evaluation for the presence of
dementia. There is much information that can be acquired by simple
observation. When the clinician is examining or interviewing the
patient, its important to pay special attention to:8
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Alertness/level of consciousness:
Whether the patient is paying attention and responding to their
surroundings
Aphasia:
Inability to express or understand language, spoken or written
Apraxia:
Inability to perform physical tasks that the patient should have
the capability of doing
Behavior:
Erratic or inappropriate behavior in the patient, observed or
reported
General appearance
Memory:
How well the patient retains and recalls information
Mood:
Unexplained mood swings in the patient, observed or reported
Orientation:
Whether the patient knows the date and time
Thought process:
Organized or disorganized thinking
The clinician should also carefully observe the patient for:1
Executive functioning, i.e., planning, weighing alternatives,
coordination of mental faculties for accomplishing tasks
General appearance and behavior
Insight and judgment
Memory, short-term and long-term
Language
Level of consciousness
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Orientation
Language
Mood and affect
Thought content
Visuospatial functions, i.e., how well the patient analyzes and
understands space in several dimensions
Neurological and psychiatric functioning can also be assessed by using
neuropsychological testing and standardized screening tests.
Neuropsychological testing is a broad term that refers to tests that are
designed to assess a single neurological function such as memory,
intelligence, or visuospatial ability. For example, memory can be
tested using the Constructional Praxis Test, and visuospatial ability can
be tested using the clock test.
Although neuropsychological tests are lengthy and complex, they can
be helpful when the initial assessment shows a cognitive deficit but the
specific problem causing the cognitive deficit is not obvious. These
tests are considered to have a relatively high sensitivity and specificity
for detecting dementia,5 and can be useful in differentiating dementia
from depression.1
Standardized screening tests can be helpful to assess for the presence
and severity of dementia, but it should be remembered that these are
used for screening; they are not diagnostic. Four screening tests that
are commonly used are the Mini-Mental State Examination (MMSE),
the Mini-Cog, The Clinical Dementia Rating (CDR) scale and the
Montreal Cognitive Assessment (MOCA). There are many other
assessment tests or tools and a full discussion of each one and their
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limits, strengths, and how and when they should be used is beyond
the scope of this study. A more indepth study on dementia screening
tests is available through the 2014 review by Yokomizo et al.17 and a
2013 review by Lin et al.20
Mini-mental status exam
The Mini-Mental Status Exam (MMSE) is commonly used. It can be
done relatively quickly, and it is the most widely studied of the
cognitive screening tests.19 The test is not considered to be sensitive
for diagnosing mild dementia and performance may be affected by age
and level of education.5 It involves performance of the following
tasks:
1. What is the date: (year)(season)(date)(day)(month) - 5 points
2. Where are we: (state)(county)(town)(hospital)(floor) - 5 points
3. Name three objects:
Name three objects and then ask the patient to repeat them.
Give one point for each correct answer. Repeat them until he or
she learns all three. Count and record the number of trials. The
first repetition determines the score, but if the patient cannot
learn the words after six trials then recall cannot be meaningfully
tested. Maximum score - 3 points.
4. Serial 7s:
Ask the patient to count backwards in increments of 7, starting
with the number 100. One point for each correct answer; stop
after five answers. Alternatively, spell WORLD backwards, one
point for each letter in correct order. Maximum score - 5 points.
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5. Ask for recall of the three objects repeated (above in #3):
one point for each correct. Maximum score - 3 points.
6. Show and ask patient to name a pencil and wrist watch - 2 points.
7. Repeat the following: "No ifs, ands, or buts." Allow only one trial -
1 point.
8. Follow a three stage command, "Take a paper in your right hand,
fold it in half, and put it on the floor." Score one point for each
task executed. Maximum score - 3 points.
9. On a blank piece of paper write "close your eyes." Then ask the
patient to read and do what it says - 1 point.
10. Give the patient a blank piece of paper and ask him or her to
write a sentence. The sentence must contain a noun and verb and
be sensible - 1 point.
11. Ask the patient to copy a design (i.e., intersecting pentagons). All
10 angles must be present and two must intersect – 1 point.
The maximum score on the MMSE is 30 points. A score of less than 24
points is usually considered to be suggestive of dementia or delirium.5
Mini-cog test
The Mini-Cog test requires the patient to: 1) draw a clock with the
numbers in correct sequence and the clock hands correctly indicating
the current time; and, 2) perform an un-cued recall of three objects.
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The names of the three objects (i.e., banana, car, dog) are given to
the patient and he or she is then asked to repeat them. After that, the
patient is asked to draw the clock and when that task has been
completed, he or she is asked to tell the interviewer the names of the
three objects. Each correctly recalled word is worth one point and the
clock is considered normal if the time is correct and the clock is grossly
normal.
Dementia is present if the score is 0 or if the patient recalls 1-2 words
and the clock is abnormal. If the patient recalls 1-2 words and the
clock is normal or if the patient recalls all 3 words, there is no
dementia. The Mini-Cog takes approximately three minutes to
administer, and it is considered to be very sensitive for detecting
dementia.5,21
Clinical dementia rating
The clinical dementia rating (CDR) was designed to assess the severity
of Alzheimer’s disease. It is rather lengthy to administer and it
depends to a degree on the subjective observations of the test
administrator, but it has been shown to be valid and sensitive.5 The
patient’s abilities in the following areas are assessed.
Community affairs
Home and hobbies
Judgment
Memory
Orientation
Problem solving
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The patient is judged on her or his abilities and performances in these
areas as follows:
0 = None
0.5 = Very mild
1 = Mild
2 = Moderate
3 = Severe
The ratings and interpretations are:
0 = Normal
0.5 to 4 = Questionable cognitive impairment
4.5 to 9 = Mild dementia
9.5 to 15.5 = Moderate dementia
≥ 16 = Severe dementia
Montreal cognitive assessment (MOCA)
The Montreal Cognitive Assessment (MOCA) has been shown to be a
useful screening tool for detecting mild levels of cognitive impairment
in patients who have Alzheimer’s disease, 22,23 for identifying people
with cognitive impairment who are at risk for developing dementia,24
and identifying patients who have dementia.26,27 The patient is
assessed in ten areas of cognitive ability, i.e., attention, memory, and
sentence repetition, and the test takes approximately 10 minutes to
administer. A complete example of the MOCA will not be presented
here as it is quite lengthy; the reader is referred to the following
website for complete information on the MOCA at
http://www.mocatest.org/.
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ASSESSMENT OF DELIRIUM
In many cases delirium is a clinical diagnosis that cannot be confirmed
by imaging studies, laboratory tests, or specific physical findings and
determining whether the patient does, or does not, have delirium will
depend on thorough history taking and patient assessment. The
assessment process outlined below can be applied to any situation in
which delirium may be present.
Vital signs
Assessment of the airway, breathing, and circulation (The ABCs), and
body temperature is always the first step of a patient assessment.
Hypo- and hyperthermia, hypoxia, hyper- and hypotension,
bradycardia, tachycardia, respiratory depression and tachypnea can be
signs of causes of delirium. Some causes of delirium include blood
loss, congestive heart failure, dehydration, drug overdose, infection,
and myocardial infarction.
History
The events in the patient’s life prior to the onset of delirium should be
reviewed, either by speaking to the patient, family members, friends,
or caretakers. The clinician should ask specific questions about
behavior, changes in social circumstances, daily activities, elimination
patterns, food and fluid intake, and mood. Its important to learn
whether there have been any recent events such as an accident,
illness, trauma, or surgery that could be a cause of delirium.
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Medical and surgical history
The patient’s medical and surgical history should be carefully
reviewed. This review should include the medical history of the
patient’s immediate family, i.e., parents and siblings. Similar to the
history taking with dementia, the history should include a thorough
investigation into the patient’s use or abuse of substances. Since he or
she may not be forthcoming or unable to inform the interviewer about
the history of substance abuse, it may be necessary to ask someone
other than the patient about the patient’s use of alcohol and/or illicit
drugs.
Medication history
A current list of the prescription medications the patient is taking and
verification of new medications recently prescribed or changes in
dosing is important. The clinician should inquire about the use of over-
the-counter and/or herbal medications. It is important to determine if
the patient has been taking his or her medications as prescribed.
There may have been an inadvertent or intentional overdose, the
patient may have been skipping doses, or he or she may have simply
stopped taking a prescribed medication.
Physical assessment
A physical examination can be difficult or impossible to perform if the
patient is agitated, confused, or uncooperative. If it is not possible to
do a complete physical examination then the clinician should do a
partial examination. An examination should be done in stages and as
much information gathered as possible by observing the patient.
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Findings from a physical examination in these situations may be
equivocal. However, the presence of some physical findings and the
absence of others can help the clinician decide which diagnostic tests
should be done and can suggest the cause of the delirium. For
example, the patient who has had a stroke may have hemiparesis or a
patient who is dehydrated will have dry mucous membranes and
decreased skin turgor.
Laboratory testing, imaging studies, and other diagnostic tools
There are no laboratory tests, imaging studies, or other diagnostic
tools that should be routinely performed for every patient who is
suspected of having delirium. The physical examination and history
taking should determine what is needed, and it is important to focus
diagnostic efforts in order to avoid unnecessary procedures and delays
in making the diagnosis. Tests that are helpful when assessing for the
presence of delirium are the CBC, BUN, creatinine, serum calcium,
electrolytes, and glucose, pulse oximetry, 12-lead ECG, and
urinalysis.9
DELIRIUM: NEUROLOGICAL AND PSYCHIATRIC EVALUATION
As with the physical examination, a complete neurological and
psychiatric evaluation may not be possible if the patient is agitated,
confused, or uncooperative. When evaluating a patient for the pesence
of delirium, carefully observe these areas of cognition and behavior:1
Executive functioning, i.e., planning, weighing alternatives
General appearance and behavior
Insight and judgment
Memory, short-term and long-term
Language
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Level of consciousness
Orientation
Language
Mood and affect
Thought content
Visuospatial functions, i.e., how well the patient analyzes and
understands space in several dimensions
The signs and symptoms of delirium include:1,11
Agitation
Anxiety
Apathy
Delusions
Difficulty with language and speech
Disorientation
Distractability
Drowsiness
Dysarthria
Dysphasia
Emotional lability
Flight of ideas
Fluctuating level of consciousness
Hallucinations
Illusions
Inability to concentrate or focus
Memory loss
Restlessness
Sleep disturbances
Tremor
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Standardized screening tests can be used to detect delirium. One of
the oldest and most commonly used in the Confusion Assessment
Method (CAM).28 The CAM has been shown to be accurate and
reliable.29,30 It is easy to administer and it can be used in a wide
variety of clinical situations.29,30 It has two parts: the first is an
assessment tool that is used to detect cognitive impairment and the
second is a short screening test that is used to distinguish delirium
from dementia. Part two is presented here, in Table 5. The diagnosis of
delirium by CAM requires the presence of features 1 and 2 and either 3
or 4.30
Table 5: The CAM Screening Test Part 2
1. Acute Onset and fluctuating course
Is there evidence of an acute change in mental status from the
patient’s baseline?
Did the abnormal behavior fluctuate during the day, i.e., tend to come
and go, or increase and decrease in severity)?
2. Inattention
Did the patient have difficulty focusing attention (i.e., being easily
distractible) or have difficulty keeping track of what was being said?
3. Disorganized thinking
Was the patient’s thinking disorganized or incoherent? Did he or she
have rambling or irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject?
4. Altered level of consciousness
How would patient’s level of consciousness be rated? Alert
(normal), vigilant (hyper-alert), lethargic (drowsy, easily aroused),
stuporous (difficult to arouse), or coma (un-arousable). If the patient’s
level of consciousness is anything other than alert, that should be
considered a positive score.
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NURSING CARE OF THE PATIENT WITH DEMENTIA
Nursing care and treatment of the patient who has dementia should
focus on:
Communication
Neuropsychiatric behavioral issues
Safety and comfort
Pain Control
Medication used to treat dementia
Communication
The patient who has Alzheimer’s disease, vascular dementia, or any
pathology that causes dementia will have problems in using and
understanding langage. He or she may have difficulty understanding
what is said, expressing ideas and emotions, and responding
appropriately.31 Hearing and speech impairments may be present and
depression may negatively influence the patient’s desire to
communicate.
Limitations of the patient with dementia does not mean the patient
needs to be isolated or that the nurse cannot have clear and
meaningful communication with the patient. The keys to overcoming
limitations are assessment and adjustment. The nurse caring for the
dementia patient needs to assess the patient’s communication abilities
and needs and then adjust their communication style. If the nurse can
do this, the interactions between the nurse and the patient will be
effective and satisfying. This is done on an individual basis but there
are some simple principles the nurse should always keep in mind when
communicating with a patient who has dementia.
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Communication problems associated with dementia do not
correspond to a loss of self-identity and studies show that the
personality endures despite these communication difficulties.32
When the patient’s self-identity is acknowledged by caregivers,
disruptive and combative behavior is often dissipated. The
challenge for caregivers is to discover the patient’s self-identity.
Families and caregivers develop effective personalized
communication patterns with patients 33 and it can be very
helpful to ask them how they communicate with the patient.
Reality orientation is a helpful communication strategy. It
involves constant, repetitive verbal and visual clues to keep the
patient oriented. This technique can improve functional abilities
in patients who have dementia.34 Potential scenarios would be
that the nurse introduces themself each time they talk to the
patient, points to calendars and clocks frequently in
conversation, and talks about current events and the plans for
the day.
Speaking clearly and slowly is important in the faciliation of
meaningful and successful conversation with the patient with
dementia. The nurse should remember to make eye contact and
use short sentences. Waiting for responses and not answering
for the patient is another helpful strategy; and, the nurse should
avoid finishing sentences for the patient or interrupting them. If
the patient cannot answer or respond correctly at first, the nurse
should try again. Being aware of one’s tone and volume of voice
and of body language is important.
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Minimizing distractions when communicating with the patient
with dementia and avoiding several conversations at the same
time will help the patient’s effort to communicate.31 The
Alzheimer’s Association publishes a guideline on communicating
with patients who have dementia that outlines some of these
strategies. These may be located at the following website:
https://www.alz.org/national/documents/brochure_communicati
on.pdf.
Neuropsychiatric behavioral problems
Neuropsychiatric behavior problems are a common and serious
complication of dementia.35,36 Agitation, aggression, anxiety, apathy,
delusions, depression, disinhibition, hallucinations, sleep disturbances,
and wandering occur quite often and they are disturbing for patients
and caregivers. They are also potentially dangerous and, if not
properly managed, can increase the incidence of morbidity and
mortality and increase length of hospital stay.
It is often assumed that these problems are simply part of dementia
and dementia does contribute to their development. However, the
cause of agitation, aggression, inappropriate actions and speech, etc.,
is almost always internal and/or external stimuli that are not obvious
to family members, caregivers, and health care professionals.35,37 The
patient who has dementia frequently has cognitive deficits that affect
his or her ability to cope, communicate, and provide self-care, and
neuropsychiatric behavior problems are simply a response to stress.
Its important for the caregiver or clinician to evaluate stressors and
the patient’s response to stressors. Considering neuropsychiatric
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behavior problems as “normal” for a patient who has dementia is in
one sense treating the patient as less than whole.
It is recommended that behavioral and environmental approaches
should be used to treat neuropsychiatric behavior problems.35
Psychotropic medications should only be used in these situations if:
non-pharmacologic interventions have failed;
the patient has major depression with or without suicidal
ideation;
the patient has a psychosis that is causing great harm or has the
potential to do so;
the patient is very aggressive and may harm him- or herself or
others.35
DICE method
The optimal approach to neuropsychiatric behavior problems can be
summarized as making every effort to understand the situation from
the patient’s point of view. A recommended method is the DICE
approach: Describe, Investigate, Create and Evaluate.35 This is a
systematic way of identifying and treating neuropsychiatric behavior
problems that operates with the assumption that such behavior
problems are caused by a stressor that can be identified and
corrected, and that these issues can be solved with creativity and
patience. The steps in the DICE method is further explained below.
Describe
In the first step of the DICE method the clinician is exploring such
questions as:
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When is the patient agitated and where is he or she when this
behavior is happening?
Who was the patient interacting with or near to when the
agitation occured?
What are the environmental conditions, the time of day?
What was the patient doing immediately before the agitation
began?
Is the patient complaining and if so, about what?
Investigate
In this step the clinician is looking for cause, by investigating such
questions as:
Was the patient recently given a medication or is he or she
scheduled for a dose?
Was the patient recently started on a medication?
Has the patient been incontinent or could he or she be in pain?
Has the patient’s daily activity schedule been changed or his or
her sleep pattern been disrupted?
What are the patient’s vital signs?
When performing this investigation it is important to remember that
many people who have dementia are elderly and have chonic medical
problems. Neuropsychiatric behavioral problems are often caused by
emotional or psychological stress, but the possibility of an acute illness
or exacerbation of an existing one should always be considered.
Create
Creating a treatment plan should be a collaborative effort between
nurses, other healthcare professionals and, if they are involved in day-
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to-day care, the family members. The clinician needs to focus on the
behavior that is problematic at the time, but also on root cause and
prevention. Strategies for the two can be different. The patient who is
agitated may need to be in a place that is quiet and away from others
- an immediate solution - but underlying causes such as over-
stimulation and pain need to be addressed.
Evaluate
In this final step, the clinican is evaluating the strategy in terms of
negative and positive consequences and how easy it was to apply.
SAFETY AND COMFORT OF THE PATIENT WITH DEMENTIA
Safety and comfort are very important areas of care. The patient who
has dementia has a decreased capacity for decision making and may
also have limited physical capabilities. Those factors increase the risk
for accidents, errors in judgment, falls, and other forms of harm.
Discomfort is a common sourcce of behavioral problems for the patient
who has dementia. He or she may be unable to communicate about
discomfort or take actions to relieve discomfort, and this can lead to
behavioral problems such as agitation or wandering. Assessment and
re-assessment of the patient and his or her environment must be done
frequently, and the clinician should always be evaluating whether the
patient is safe and comfortable.
Pain control
Pain is very common in patients who have dementia.38,39 Patients who
have dementia do not experience any less pain than older adults
without dementia, but assessment for pain in this patient population is
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challenging. Patients who have dementia may not interpret sensations
as painful, have difficulty recalling pain in the recent past, and may be
unable to tell someone about their pain.40 In addition, the patient who
has dementia may be prescribed analgesics, anti-psychotics, or other
medications that can blunt their response to pain. Untreated pain can
cause behavioral problems and psychological distress39, and untreated
pain in any patient is unacceptable.
Assessment for the presence of pain and evaluating the success of
treatments for pain depends in large part on self-reporting: the patient
will tell us how much pain he or she is having and if the interventions
provided reflief. However, for the patient who has dementia this is
seldom an option. Nurses and other healthcare professionals will need
to use professional judgement and an assessment tool.
There are many pain assessment tools available, but it is not clear
which ones are best for this clinical application .39 Corbett et al.
(2014) in a recent review noted that the Mobilization-Observation-
Behavior-Intensity-Dementia-2 (MOBID-2) pain assessment tool is “ . .
arguably the most promising of recently evaluated tools . . . “ It was
very reliable for detecting the presence of pain in patients who have
dementia and could also be used to assess the response to pain
treatments.39 The MOBID-2 uses: 41
1. The patient’s observed responses (facial expression, aversive or
defensive behavior, and noises indicating the presence of pain)
to five simple physical tasks, i.e., stretching both arms towards
the head;
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2. Observations by the nurse or other caregiver of patient behavior
during normal daily actvities that may indicate the presence of
pain.
Medications used to treat dementia
The drugs most commonly used to treat dementia are the
cholinesterase inhibitors.42 The four cholinesterase inhibitors currently
available are donepezil (Aricept®), galantamine (Razadyne®),
rivastigmine (Exelon®), and tacrine (tacrine is no longer used in the
US because it can cause severe side effects).42 These drugs inhibit the
activity of cholinesterase at the synaptic cleft and increasing
cholinergic transmission. Patients who have Alzheimer’s disease have a
decreased cerebral synthesis of acetylcholine, but the cholinesterase
inhibitors are used to treat vascular dementia, Lewy body disease,
frontotemporal dementia, and other forms of dementia.
The cholinesterase inhibitors can produce a mild improvement in
cognition and increase the ability to perform activities of daily living,
and they may delay progression of cognitive defects.1,37,42 The long-
term benefits of the use of cholinesterase inhibitors for patients who
have dementia is still being determined. It is not known which patients
who have dementia should be prescribed these drugs and the optimum
duration of therapy.42 Regardless, most sources recommend a trial
period of cholinesterase inhibitors and donepezil, galantamine, or
rivastigmine; and, they appear to be equally effective.42 The dose
should be slowly titrated and at the end of eight weeks of the
maximum dose the patient should be re-assessed. If there is no
improvement, the drug should be stopped.42
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Donepezil, galantamine, and rivastigmine are available as oral tablets,
solution, sustained-release capsules, and transdermal patch. Because
of their mechanism of action, gastrointestinal effects such as diarrhea,
nausea, and vomiting are very common. Agitation, ataxia, dizziness,
headache are also common adverse effects.
Memantine (Namenda®) is an N-methyl-D-aspartate (NMDA) receptor
antagonist. N-methyl-D-aspartate is a neurotransmitter that mimics
the action of glutamate, a major excitatory neurotransmitter.
Memantine has a labeled use for the treatment of moderate to severe
dementia associated with Alzheimer’s disease and an unlabeled use for
the treatment of mild to moderate vascular dementia. Used alone or
with cholinesterase inhibitors, memantine helps improve cognition and
performance of activities of daily living, and it may slow progression of
the disease.43 Common adverse reactions effects of memantine include
confusion, dizziness, and headache. The drug is available as oral
tablets, solution, and extended-release capsules.
Anti-psychotics should be avoided.1 The evidence of their effectiveness
for treating patients who have dementia is very limited44,45 and there
is clear evidence that these drugs increase the risk of stroke and
mortality in elderly patients with dementia.37,46 Additionally, anti-
depressants and hypnotics appear to have limited effectiveness for
patients with dementia.37 Other medications that have been used to
treat patients who have dementia, either for symptomatic relief or as
preventative measures include: estrogen, folic acid, gingko biloba,
non-steroidal anti-inflammatories, selegiline, statins, vitamin B6,
vitamin B12, and vitamin E.1,43 At this time, there is no evidence that
any of these drugs are effective.1,43
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Other therapies and interventions
Cognitive rehabilitation, formalized exercise programs, and
occupational therapy are relatively risk-free interventions that have
been shown to be of benefit for patients who have dementia.43
NURSING CARE OF THE PATIENT WITH DELIRIUM
Delirium is considered to be a medical emergency.2 Therapies and
interventions that would be appropriate when treating most patients
who have delirium would be:9,47
Hydration
Assess the level of stimulation. Under- and over-stimulation can
be a problem for patients who have delirium.
Re-orientation techniques
Bedside sitter
If possible and if it helps, close contact with a family member or
someone familiar to the patient is encouraged.
Make sure the patient has his or her corrective lenses and/or
hearing aid, if they use these.
Maintain normal sleep patterns.
Assess for and treat pain.
Physical restraints should not be used unless other interventions have
failed and there is risk to the patient or others.9,47,48 The standard
pharmacological therapy for treating patients who have delirium and
are agitated is haloperidol.9 Haloperdiol and other antipsychotics, i.e.,
aripiprazole, olanzapine, quetiapine, and risperidone have all been
shown to be effective in treating delirium, but the effect is modest and
when they are compared there is no evidence that any one of the
antipsychotics offers a significant advantage.49-51 Drowsiness and
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extrapyramidal effects are common adverse effects of the
antipsychotics.
SUMMARY
Dementia and delirium are neurological disorders that cause signficant
cognitive impairment and increase the risk of morbidity and mortality.
These diseases can be difficult to detect and diagnose. Some cases of
dementia and many cases of delirium are reversible, but dementia is
most often chronic, progressive, and cannot be cured; and, the
dementias and deliriums that are considered reversible may result in
serious complications. The most common cause of dementia is
Alzheimer’s disease. Medications and dementia appear to be the most
common causes of delirium.
Advanced age itself is not a cause of either disease, but the elderly do
have a high risk for developing dementia and delirium; and, as the US
population continues to get older, the incidences of dementia and
delirium are likely to increase. Treatment of dementia and delirium is
primarily symptomatic and supportive unless there is a clearly
identified etiology. Primary concerns when providing nursing care for
the patient who has either dementia or delirium are: monitoring of
vitals signs, behavioral and environmental interventions, safety and
comfort, pain control, and safe administration of medications.
Please take time to help the NURSECE4LESS.COM course planners evaluate
nursing knowledge needs met following completion of this course by
completing the self-assessment Knowledge Questions after reading the
article. Correct Answers, pg. 48.
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1. One of the defining characteristics of dementia is:
a. inability to perform activities of daily living.
b. severe agitation.
c. reversible cognitive impairment.
d. occurrence before age 50.
2. Most cases of dementia are caused by:
a. trauma and heavy metal poisoning.
b. infections and hemorrhage.
c. Alzheimer’s disease and vascular pathologies.
d. hypoxia and Parkinson’s disease.
3. Defining characteristics of delirium include:
a. Movement disorders and a progressive cognitive decline.
b. Attention deficits and confusion.
c. Expressive aphasia and hypotension.
d. Hyperthermia and depression.
4. Common causes of delirium include:
a. Parkinson’s disease and advanced age.
b. Drug withdrawal and Lewy body dementia.
c. Acute blood loss and frontotemporal dementia
d. Drugs and dementia.
5. True or false: Dementia is an inevitable consequence of
aging.
a. True.
b. False.
6. Dementia is often misdiagnosed as:
a. depression.
b. mild cognitive impairment.
c. Alzheimer’s disease.
d. anxiety.
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7. Use physical restraints with patients who have dementia or
delirium:
a. if the patient is agitated or confused.
b. when there is a significant risk for a fall.
c. if all other interventions fail and there is a serious risk of harm.
d. if the patient is likely to wander.
8. Neuropsychiatric behavior problems in patients who have
dementia:
a. are caused by an external or internal stimulus.
b. typically occur randomly and without cause.
c. only occur if patients are over-medicated.
d. happen primarily at night.
9. The use of anti-psychotics to treat patients with dementia:
a. is considered first-line therapy.
b. is most effective when used in conjunction with cholinesterase
inhibitors.
c. can reverse the progress of dementia.
d. is questionably effective and potentially dangerous
10. The drug most commonly used to treat agitation in patients
who have delirium is:
a. diazepam.
b. haloperidol.
c. galantamine.
d. bupropion.
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CORRECT ANSWERS:
Footnotes:
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