Caring for Persons With Confusion and Dementia

Caring for Persons With Confusion and Dementia

Key Abbreviations

AD Alzheimer’s disease

ADL Activities of daily living

NIA National Institute on Aging

OBRA Omnibus Budget Reconciliation Act of 1987

• Define the key terms and key abbreviations listed in this chapter.

• Describe confusion and its causes.

• List the measures that help confused persons.

• Explain the differences between delirium, depression, and dementia.

• Describe the signs, symptoms, and behaviors of Alzheimer’s disease (AD).

• Explain the care required by persons with AD and other dementias.

• Describe the effects of AD on the family.

• Explain validation therapy.

• Explain how to promote PRIDE in the person, the family, and yourself.

Changes in the brain and nervous system occur with aging and certain diseases (Box 30-1). Cognitive function may be affected. (Cognitive relates to knowledge.) Quality of life is affected. Cognitive function involves memory, thinking, reasoning, ability to understand, judgment, and behavior.

Box 30-1 Nervous System Changes From Aging

• Nerve cells are lost.

• Nerve conduction slows.

• Responses and reaction times are slower.

• Reflexes are slower.

• Vision and hearing decrease.

• Taste and smell decrease.

• Touch and sensitivity to pain decrease.

• Blood flow to the brain is reduced.

• Sleep patterns change.

• Memory is shorter.

• Forgetfulness occurs.

• Dizziness can occur.

Confusion

Confusion is a mental state of being disoriented to person, time, place, situation, or identity. Disease, brain injury, infections, hearing and vision loss, and drug side effects are some causes. With aging, blood supply to the brain is reduced. Personality and mental changes can result. Memory and ability to make good judgments are lost. A person may not know people, the time, or the place. Daily activities may be affected. Behavior changes are common. The person may be angry, restless, depressed, and irritable.

Acute confusion (delirium—p. 468) occurs suddenly. It is usually temporary. Causes include infection, illness, injury, drugs, and surgery. Treatment is aimed at the cause.

Confusion from physical changes cannot be cured. Some measures help improve function (Box 30-2). You must meet the person’s basic needs.

Box 30-2 Caring for Persons With Confusion

• Follow the person’s care plan.

• Provide for safety.

• Face the person. Speak clearly.

• Call the person by name every time you have 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. 30-1). Remind the person of holidays, birthdays, and other events.

FIGURE 30-1 A large calendar can help persons who are confused.

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

• Use touch to communicate (Chapter 6).

• Place familiar objects and pictures within 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 crowded 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.) Changes in personality, mood, behavior, and communication are common. Dementia occurs when the brain is damaged by disease or injury.

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

• Memory loss (losing things, forgetting names)

• Problems with common tasks (for example, dressing, cooking, driving)

• Problems with language and communication; forgetting simple words

• Getting lost in familiar places

• Misplacing things and putting things in odd places (for example, putting a watch in the oven)

• Personality, mood, and behavior changes

• Poor or decreased judgment (for example, going outdoors in the snow without shoes)

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

• Drugs and alcohol

• Delirium and depression (p. 468)

• Heart, lung, and blood vessel problems

• Head injuries

• Vision and hearing problems

Permanent dementias result from changes in the brain. The causes in Box 30-3, p. 468 have no cure. Function declines over time. Alzheimer’s disease is the most common type of permanent dementia.

Box 30-3 Causes of Permanent Dementia

• AIDS-related dementia

• Alcohol-related dementia and Korsakoff’s syndrome

• Alzheimer’s disease

• Brain tumors

• Cerebrovascular disease

• Huntington’s disease (a nervous system disease)

• Multi-infarct dementia (MID)—many (multi) strokes leave areas of damage (infarct)

• Multiple sclerosis

• Parkinson’s disease

• Trauma and head injury

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 changes in brain function. Usually temporary and reversible, it occurs with physical or mental illness. Causes include acute or chronic illness, surgery, drug or alcohol abuse, and infections. Delirium often lasts for about 1 week. However, it may take several weeks for normal mental function to return.

Delirium signals physical illness. It is an emergency. The cause must be found and treated. See Box 30-4 for signs and symptoms.

Box 30-4

Signs and Symptoms of Delirium

• Alertness: changes in. The person is usually more alert in the morning and less alert at night.

• Sensation: changes in.

• Awareness: changes in.

• Movement: very active or slow moving.

• Drowsiness.

• Confusion about time or place.

• Decreased short-term memory and recall. Cannot remember events since the delirium began.

• Cannot remember past events.

• Thinking and behavior are without purpose.

• Problems concentrating.

• Speech does not make sense.

• Emotional changes:

• Irritability

• Incontinence.

• Restlessness.

Modified from MedlinePlus: Delirium, Bethesda, Md, updated March 22, 2013, U.S. National Library of Medicine, National Institutes of Health.

Depression

Depression is the most common mental health disorder in older persons. It is often overlooked. Depression, aging, and some drug side effects have similar signs and symptoms. See Chapter 29 for signs and symptoms of depression in older persons.

Alzheimer’s Disease

Alzheimer’s disease (AD) is a brain disease. Many brain cells are destroyed and die (Fig. 30-2). These functions are affected:

FIGURE 30-2 A, Normal brain. B, Dark patches show damage to brain tissue.

• Personality

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

The onset is gradual. Usually symptoms first appear after age 60. The person can live 3 to 4 years or as long as 10 or more years. Nearly half of persons age 85 and older have AD. More women than men have AD. Women live longer than men.

AD is not a normal part of aging. The cause is unknown. A family history of AD increases a person’s risk of developing the disease.

Signs of AD

According to the Alzheimer’s Association, the most common early symptom of AD is difficulty remembering newly learned information. The classic sign of AD is a gradual loss of short-term memory. At first, the only symptom may be forgetfulness. Box 30-5 lists the warning and other signs of AD. See Box 30-6 for the differences between AD and normal age-related changes.

Box 30-5 Signs of Alzheimer’s Disease

• Asks the same question over and over again.

• Repeats the same story—word for word, again and again.

• Forgets activities that were once done regularly and with ease—cooking, repairs, playing cards, and so on.

• Loses the ability to pay bills or balance a checkbook.

• Gets lost in familiar places.

• Misplaces household items.

• Neglects to bathe. Or wears the same clothes over and over again.

• Relies on someone else to make decisions or answer questions that he or she would have handled.

• Forgets recent events, conversations, and appointments.

• Forgets simple directions.

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

• Forgets words, cannot find the right word, or loses train of thought.

• Substitutes unusual words and names for what is forgotten.

• Speaks in a native language.

• Curses or swears.

• Forgets important dates and events.

• Takes longer to do things.

• Misplaces things. Puts things in odd places.

• Has problems keeping track of bills and writing checks.

• Gives away large amounts of money.

• Does not recognize or understand numbers.

• Has problems following conversations.

• Has problems reading and writing.

• Has problems driving to familiar places.

• Forgets where he or she is.

• Forgets how he or she got to a certain place.

• Does not know how to get back home.

• Wanders from home.

• Cannot tell or understand time or dates.

• Cannot solve everyday problems (iron 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.

• Does not want to do things and withdraws socially.

• Is restless.

• Becomes suspicious and fearful.

• Sleeps more than usual.

Warning signs modified from Eric Pfeiffer, MD: The seven warning signs of Alzheimer’s disease, University of South Florida Suncoast Alzheimer’s and Gerontology Center. Reprinted with permission.

Box 30-6 Alzheimer’s Disease and Normal Aging

Signs of AD	Normal Age-Related Changes
• Poor judgment and decision making. • Cannot manage a budget. • Loses track of the date or season. • Problems having a conversation. • Misplaces things. Cannot retrace steps to find them.	• Makes a bad decision once in a while. • Misses a monthly payment. • Forgets which day it is but remembers later. • Sometimes forgets which word to use. • Loses things from time to time.

Modified from Alzheimer’s Association: 10 early signs and symptoms of Alzheimer’s, 2013

Stages of AD

Signs and symptoms become more severe as the disease progresses. The disease ends in death. AD is often described in 3 stages (Box 30-7; Fig. 30-3). The Alzheimer’s Association describes AD in 7 stages (Box 30-8).

Box 30-7

Three Stages of Alzheimer’s Disease—National Institute on Aging

• Memory problems

• Getting lost

• Problems handling money and paying bills

• Repeating questions

• Taking longer to complete daily tasks

• Poor judgment

• Losing things or misplacing them in odd places

• Mood and personality changes

• Increased memory loss and confusion

• Problems recognizing family and friends

• Cannot learn new things

• Problems with tasks having multiple steps—getting dressed is an example

• Problems coping with new situations

• Hallucinations, delusions, and paranoia (p. 472)

• Impulsive behavior

• Depends on others for care

• Cannot communicate

• Weight loss

• Skin infections

• Difficulty swallowing

• Groaning, moaning, or grunting

• Increased sleeping

• In bed most or all of the time

• Lack of bowel and bladder control

Modified from National Institute on Aging: About Alzheimer’s disease: symptoms, National Institutes of Health.

Box 30-8

Seven Stages of Alzheimer’s Disease—Alzheimer’s Association

Stage 1—No Impairment

• No signs of memory problems.

Stage 2—Very Mild Cognitive Decline

• Memory lapses.

• Forgets familiar words.

• Forgets location of everyday things.

• Symptoms are not noticed by others.

Stage 3—Mild Cognitive Decline

• Symptoms are noticed by others.

• Memory or concentration problems.

• Problems with the right words or names.

• Problems remembering names of new people.

• Increased problems with tasks in social or work settings.

• Forgets what was just read.

• Loses or misplaces a valuable object.

• Increased problems planning and organizing.

Stage 4—Moderate Cognitive Decline

• Forgets recent events.

• Problems with arithmetic. Counting backward from 100 by subtracting 7 (100, 93, 86, 79, 72, and so on) is an example.

• Increased difficulty with complex tasks. Paying bills and managing money are examples.

• Forgets things about one’s past.

• Becomes moody or withdrawn in social situations.

Stage 5—Moderately Severe Cognitive Decline

• Noticeable gaps in memory and thinking.

• May need help with activities of daily living (ADL).

• Cannot recall his or her address or phone number.

• Confusion about day, time, and place.

• Problems with simple arithmetic. Counting backward from 40 by subtracting 4 (40, 36, 32, 28, 24, and so on) is an example.

• Needs help choosing clothing.

• Can remember things about family and self.

• Can eat and meet elimination needs.

Stage 6—Severe Cognitive Decline

• Memory problems worsen.

• Personality and behavior changes. See “Behaviors and Problems.”

• Needs much help with ADL.

• Loses awareness of recent things and the setting.

• Remembers his or her own name but has problems with personal past.

• Can distinguish between familiar and unfamiliar faces.

• Problems remembering the name of a spouse, partner, or caregiver.

• Sleep patterns change. May sleep during the day and be restless at night.

• Bladder and bowel control problems increase.

• Tends to wander and may become lost.

Stage 7—Very Severe Cognitive Decline

• Cannot respond to his or her setting.

• Unable to have a conversation. May say words or phrases.

• Cannot control movement.

• Needs great assistance with ADL.

• Cannot smile.

• Cannot hold the head up or sit without support.

• Muscles become rigid.

• Impaired swallowing.

Modified from Alzheimer’s Association: Seven stages of Alzheimer’s, 2013.

Behaviors and Problems

AD changes how a person behaves and acts. Besides the signs and symptoms in Boxes 30-5, 30-7, and 30-8, these changes are common.

• Wandering and getting lost

• Sundowning (p. 472)

• Hallucinations (p. 472)

• Delusions (p. 472)

• Paranoia (p. 472)

• Catastrophic reactions (p. 472)

• Agitation and aggression (p. 472)

• Communication problems (p. 473)

• Screaming (p. 473)

• Repetitive behaviors (p. 474)

• Changes in intimacy and sexuality (p. 474)

• Rummaging and hiding things (p. 474)

Health problems can make the problems worse. Examples include illness, infection, drugs, lack of sleep, constipation, hunger, thirst, poor vision or hearing, alcohol, and caffeine. So can problems in the person’s setting. They include:

• A strange setting. The person does not know the setting well.

• Too much noise (TV, radio, music, people talking at once) can cause confusion and frustration.

• Not understanding signs. The person may think that a wet floor sign means to urinate on the floor.

• Mirrors. The person may think that a mirror image is another person in the room.

Only gold members can continue reading. Log In or Register to continue

Related

Stay updated, free articles. Join our Telegram channel

Tags: Mosbys Essentials for Nursing Assistants

Nov 5, 2016 | Posted by admin in MEDICAL ASSISSTANT | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access