44. Confusion and dementia


Confusion and dementia


Objectives



Key terms


cognitive function  Involves memory, thinking, reasoning, ability to understand, judgment, and behavior


delirium  A state of sudden, severe confusion and rapid brain changes


delusion  A false belief


dementia  The loss of cognitive function that interferes with routine personal, social, and occupational activities


elopement  When a person leaves the center without staff knowledge


hallucination  Seeing, hearing, smelling, or feeling something that is not real


paranoia  A disorder (para) of the mind (noia); the person has false beliefs (delusions) and suspicion about a person or situation


pseudodementia  False (pseudo) dementia


sundowning  Signs, symptoms, and behaviors of AD increase during hours of darkness


KEY ABBREVIATIONS

















AD Alzheimer’s disease
ADL Activities of daily living
NIA National Institute on Aging
OBRA Omnibus Budget Reconciliation Act of 1987

Changes in the brain and nervous system occur with aging (Box 44-1). Certain diseases affect the brain. Changes in the brain can affect cognitive function. (Cognitive relates to knowledge.) Quality of life is affected. Cognitive function involves:




Confusion


Confusion has many causes. Diseases, infections, hearing and vision loss, and medication side effects are some causes. So is brain injury. With aging, blood supply to the brain is reduced. Personality and mental changes can result. Memory and the ability to make good judgments are lost. A person may not know people, the time, or the place. Some people gradually lose the ability to perform daily activities. Behavior changes are common. The person may be angry, restless, depressed, and irritable.


Acute confusion (delirium) occurs suddenly. It is usually temporary. Causes include infection, illness, injury, medications, and surgery. Treatment is aimed at the cause.


Confusion caused by physical changes cannot be cured. Some measures help to improve function (Box 44-2). You must meet the person’s basic needs.




Box 44-2


Caring for the Person With Confusion



• Follow the person’s care plan.


• Provide for safety.


• Face the person. Speak clearly.


• Call the person by name every time you are in contact with him or her.


• State your name. Show your name tag.


• Give the date and time each morning. Repeat as needed during the day or evening.


• Explain what you are going to do and why.


• Give clear, simple directions and answers to questions.


• Ask clear and simple questions. Give the person time to respond.


• Keep calendars and clocks with large numbers in the person’s room and in nursing areas (Fig. 44-1). Remind the person of holidays, birthdays, and special events.


• Have the person wear eyeglasses and hearing aids as needed.


• Use touch to communicate (Chapter 8).


• Place familiar objects and pictures within the person’s view.


• Provide newspapers, magazines, TV, and radio. Read to the person if appropriate.


• Discuss current events with the person.


• Maintain the day-night cycle.


• Open window coverings during the day. Close them at night.


• Use night-lights at night. Use them in rooms, bathrooms, hallways, and other areas.


• Have the person wear regular clothes during the day—not sleepwear.


• Provide a calm, relaxed, and peaceful setting. Prevent loud noises, rushing, and congested hallways and dining rooms.


• Follow the person’s routine. Meals, bathing, exercise, TV, bedtime, and other activities have a schedule. This promotes a sense of order and what to expect.


• Break tasks into small steps when helping the person.


• Do not re-arrange furniture or the person’s belongings.


• Encourage the person to take part in self-care.


• Be consistent.



Dementia


Dementia is the loss of cognitive function that interferes with routine personal, social, and occupational activities. (De means from. Mentia means mind.) The person may have changes in personality, mood, or behavior. Dementia is a group of symptoms that may occur with certain diseases or conditions.


Dementia is not a normal part of aging. Most older people do not have dementia. Early warning signs include:



If changes in the brain have not occurred, some dementias can be reversed. When the cause is removed, so are the signs and symptoms. Treatable causes include:



Permanent dementias result from changes in the brain. They have no cure. Function declines over time. Causes of permanent dementia are listed in Box 44-3. Alzheimer’s disease is the most common type of permanent dementia.



Pseudodementia means false (pseudo) dementia. The person has signs and symptoms of dementia. However, there are no changes in the brain. This can occur with delirium and depression. Both can be mistaken for dementia.


Delirium


Delirium is a state of sudden, severe confusion and rapid brain changes. It occurs with physical or mental illness. Usually temporary and reversible, it is common in older persons with acute or chronic illnesses. Infections, heart and lung diseases, and poor nutrition are common causes. So are hormone disorders. Hypoglycemia is also a cause (Chapter 41). Alcohol and many drugs (including prescription medications) can cause delirium. Delirium often lasts for about 1 week. However, it may take several weeks for normal mental function to return.


Delirium signals physical illness in older persons and in persons with dementia. It is an emergency. The cause must be found and treated. Signs and symptoms are listed in Box 44-4.



Depression


Depression is the most common mental health problem in older persons. It is often overlooked. Depression, aging, and some medication side effects have similar signs and symptoms. See Chapter 43 for signs and symptoms of depression in older persons.


Mild cognitive impairment


Mild cognitive impairment (MCI) is a type of memory change. The person has problems with memory, language, and other mental functions (attention, judgment, reading, writing). The person or others may notice the problems. However, the problems do not interfere with daily life. The person is at risk for Alzheimer’s disease.


Alzheimer’s disease


Alzheimer’s disease (AD) is a brain disease. Many nerve cells that control intellectual and social function are damaged and die (Fig. 44-2). These functions are affected:




The person has problems with work and everyday functions. Problems with family and social relationships occur. There is a steady decline in memory and mental function.


The disease is gradual in onset. It gets worse and worse over time. Persons with AD usually live 8 to 10 years after diagnosis. Some persons live as few as 3 years. Others live as long as 20 years. Some people in their 40s and 50s have AD. However, usually symptoms first appear after the age of 60. The risk increases with age. It is often diagnosed around the age of 80. Nearly half of the persons age 85 and older have AD.


The cause is unknown. A family history of AD increases a person’s risk of developing the disease. More women than men have AD. Women live longer than men.


Signs of AD


The classic sign of AD is gradual loss of short-term memory. At first, the only symptom may be forgetfulness. Box 44-5 lists the warning signs and other signs of AD. See Box 44-6 for the difference between AD and normal age-related changes.




Box 44-5


Signs of Alzheimer’s Disease


Warning signs



Other signs



• Forgets recent events, conversations, and appointments.


• Forgets simple directions.


• Forgets names (including family members).


• Forgets the names of everyday things (clock, radio, TV, and so on).


• Forgets words, loses train of thought.


• Substitutes unusual words and names for what is forgotten.


• Speaks in a native language.


• Curses or swears.


• Misplaces things. Puts things in odd places.


• Has problems writing checks.


• Gives away large amounts of money.


• Does not recognize or understand numbers.


• Has problems following conversations.


• Has problems reading and writing.


• Becomes lost in familiar settings.


• Forgets where he or she is.


• Does not know how to get back home.


• Wanders from home.


• Cannot tell or understand time or dates.


• Cannot solve everyday problems (iron is left on, stove burners left on, food burning on the stove, and so on).


• Cannot perform everyday tasks (dressing, bathing, brushing teeth, and so on).


• Distrusts others.


• Is stubborn.


• Withdraws socially.


• Is restless.


• Becomes suspicious.


• Becomes fearful.


• Does not want to do things.


• Sleeps more than usual.


Warning signs written by Eric Pfeiffer, MD, the director of the University of South Florida Suncoast Alzheimer’s and Gerontology Center. Reprinted with permission.



Stages of AD


Signs and symptoms become more severe as the disease progresses. The disease ends in death. AD is often described in terms of 3 stages (Box 44-7). See Figure 44-3. The Alzheimer’s Association describes seven stages:



• No impairment. The person does not show signs of memory problems.


• Very mild cognitive decline. The person thinks that he or she has memory loss or lapses. Familiar words or names are forgotten. The person does not know where to find keys, eyeglasses, or other objects. These problems are not apparent to family, friends, or the health team.


• Mild cognitive decline. Family, friends, and others notice problems. The person has problems with memory or concentration and with words or names. The person loses or misplaces something valuable. Functioning in social or work settings declines.


• Moderate cognitive decline (mild or early stage). Memory of recent or current events declines. There are problems with shopping, paying bills, and managing money. The person may withdraw or be quiet in social situations.


• Moderately severe cognitive decline (moderate or mid-stage). The person has major memory problems. There may be confusion about the date or day of the week. He or she may need help choosing the correct clothing to wear. The person knows his or her own name, a partner’s name, and children’s names. Usually help is not needed with eating or elimination.


• Severe cognitive decline (moderately severe or mid-stage). Memory problems are worse. Personality and behavior changes develop—delusions, hallucinations, repetitive behavior. The person needs much help with daily activities, including dressing and elimination. Names may be forgotten, but faces may be recognized. Sleep problems, incontinence (urinary and fecal), and wandering are common.


• Very severe cognitive decline (severe or late stage). The person cannot respond to his or her setting, speak, or control movement. The person cannot walk without help. Over time, he or she cannot sit up without support or hold the head up. Muscles become rigid. Swallowing is impaired.




Box 44-7


Stages of Alzheimer’s Disease


Stage 1: mild AD



Stage 2: moderate AD



• Restlessness—increases during the evening hours


• Sleep problems


• Memory loss increases:


• May not know family and friends


• May not know where he or she is


• May not know the day or year


• May wander


• Dulled senses—cannot tell the difference between hot and cold; cannot recognize dangers


• Fecal and urinary incontinence


• Needs help with activities of daily living (ADL)—bathing, feeding, and dressing self; afraid of bathing; will not change clothes


• Loses impulse control—foul language, poor table manners, sexual aggression, rudeness


• Movement and gait problems—walks slowly, has a shuffling gait


• Communication problems—cannot follow directions; problems with reading, writing, and math; speaks in short sentences or single words; statements may not make sense


• Repeats motions and statements—moves things back and forth constantly; says the same thing over and over again


• Agitation—behavior may be violent


• May make threats, accuse others of stealing, curse, kick, hit, bite, scream, or grab things


Stage 3: severe AD




Behaviors and problems


AD changes how a person behaves and acts. These changes are common:



Health-related issues can make the problems worse. Examples include illness, infection, medications, lack of sleep, constipation, hunger, thirst, poor vision or hearing, alcohol, and caffeine. So can problems in the person’s setting. According to the National Institute on Aging (NIA), they include:


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Nov 5, 2016 | Posted by in MEDICAL ASSISSTANT | Comments Off on 44. Confusion and dementia

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