TYPE OF DEMENTIA	RATE (%)
Alzheimer disease	60-80
Vascular dementias with Alzheimer disease	10
Supranuclear palsy	8
Parkinsonian dementia	7
Vascular dementias (multiinfarct dementia)	5
Alzheimer disease plus dementia with Lewy bodies	5
Dementia with Lewy bodies
AIDS dementia complex
Frontal lobe dementia

AIDS, Acquired immunodeficiency syndrome.

Alzheimer disease (AD) is the most common type of dementia and accounts for approximately 70% of cases of the disease. However, AD is not a normal part of aging.

In the United States, early-onset dementia affects more than one-half million people younger than 65 years of age. In younger adults, early symptoms may be mistaken as stress or depression (Hunt, 2011). Dementia forces individuals to assume dependent roles within their families at a time when they may be primary caretakers themselves. Facts and figures about AD are presented in Box 22-2.

BOX 22-2 ALZHEIMER DISEASE FACTS AND FIGURES

• AD is not just memory loss. AD kills.

• AD is the sixth leading cause of death in the United States and the fifth leading cause of death for those aged 65 and older.

• AD is the only cause of death among the top 10 in the United States without a known prevention or cure.

• Deaths from AD increased 66% between 2000 and 2008, whereas deaths from other major diseases, including the number 1 cause of death (heart disease), decreased.

• Today, 5.4 million Americans are living with AD. By 2050, as many as 16 million Americans will have the disease.

• Two thirds of those with AD are women.

• One in eight Americans aged 65 years and older has AD, and almost half of those aged 85 and older have the disease.

• Most people survive 4 to 8 years after being diagnosed with AD, but some live as long as 20 years with the disease.

• Four percent of the general population will be admitted to a nursing home by age 80. But 75% of those with AD will be admitted to a nursing home by age 80.

• In 2010, 14.9 million family members and friends provided 17 billion hours of unpaid care for people with AD and other dementias.

• More than 60% of caregivers for people with AD or dementia rate the emotional stress of caregiving as high or very high; one third report symptoms of depression.

Adapted from http://www.alz.org/alzheimers_disease_facts_and_figures.asp. Accessed October 2011.

QUALITY AND SAFETY ALERT

• Early-onset AD is associated with a more rapid course and genetic predisposition compared with late-onset AD.

The following clinical example demonstrates the behaviors associated with dementia.

CLINICAL EXAMPLE

Mr. B is a 73-year-old widower who has resided in a retirement home for 3 years. He chose to move to the retirement home after his wife’s death even though his son encouraged him to live with him and his family. Mr. B stated that he did not want to burden his family and would be happier with others of his same age. He did well for the first 18 months. He was an active participant in social groups both in the home and in his church, which he continued to attend regularly. He also visited his son weekly and enjoyed seeing his grandchildren.

About 18 months ago, Mr. B began to seem forgetful. He would ask the same question several times and on occasion prepared for church on a Friday or Saturday. He also became irritable and accused his son of not caring about him and of abandoning him in “that place.” Mr. B spent many hours taking papers from his desk and studying them. When asked what he was doing, he would say, “Attending to my business.”

He began to withdraw from activities and make flimsy excuses to avoid playing his favorite card game, gin rummy. When persuaded to play, he usually quit in frustration because he could not remember which cards had been played. Mr. B was quite anxious at times. He seemed well oriented at times and expressed great concern about the changes he was experiencing, wondering if he was “going crazy.”

Because of the concern of the retirement home staff, Mr. B was scheduled for a complete physical examination by his family physician and for a psychiatric evaluation by the geriatric psychiatric nurse consultant who came to the retirement home each week. The physical examination found Mr. B to be in generally good health for a man his age. He had a mild hearing loss and slight prostatic hypertrophy. Hypertension had been diagnosed 10 years before this examination but was well controlled by diuretics. A neurological examination revealed normal reflexes, normal muscle strength, a slight intention tremor, normal responses to sensation, normal cranial nerves, and no disturbance of gait. The results of electroencephalography (EEG) were normal, as were those of laboratory studies of blood and urine. Computed tomography (CT) studies of the brain revealed some atrophy of the cerebral cortex.

The mental status examination confirmed the deficits in cognitive functioning observed by the nursing home staff and Mr. B’s son. Mr. B was oriented to person and place but stated the date as April 6, 1958 (the real date was January 21, 2010). He also thought the day of the week was Friday, and it was actually Wednesday. He correctly identified the season of the year as winter. Mr. B was able to state correctly his birth date, the date of his son’s birth, and the year he began to work at his first job.

He spoke at length and with great detail about his exploits as a young man. His vocabulary was excellent, as was his fund of general information. However, he could not repeat the names of three objects after 5 minutes and could not remember what he had eaten for lunch or the last name of the man who shared his room. He became distressed while trying to answer these questions. He was unable to remember the names of the two most recent presidents but could recite the names of the eight presidents before them.

Mr. B’s judgment was somewhat impaired. When asked what he would do if he found a stamped, addressed, sealed envelope, he said he would “read it, then mail it.” His abstract thinking was concrete, as was seen in his difficulty in interpreting proverbs. His attention span and ability to concentrate were normal. His eye-hand coordination was disrupted, as demonstrated by difficulty in copying simple figures. A hand tremor was evident both when he was drawing and when he was signing his name.

Mr. B’s affect was appropriate to the content of the discussion both in quality and in quantity. He appeared depressed when talking about his memory loss but cheerful and proud when describing his grandchildren. No abrupt mood swings were noted. His flow of speech was of a normal rate and volume. The content of his speech was logical and coherent but became somewhat disjointed when he tried to remember and describe recent events.

As a result of the data gathered in the physical and mental status examinations, Mr. B was diagnosed as having dementia not otherwise specified. Over the next several months his condition continued to deteriorate gradually. He became increasingly forgetful and began to confabulate and fabricate stories. He was less conforming to social norms and needed to be reminded about hygiene and appropriate dress. He also became seductive with female residents and staff, making suggestive remarks and occasionally fondling someone.

Visits to his son’s home became impossible as his behavior deteriorated. His memory of the identity of family members was sometimes confused. He would misidentify his daughter-in-law as his wife and his grandson as his son. His conversation increasingly consisted of rambling reminiscences about his life in his youth. His son and health care providers began to discuss plans to move him to the assisted living program associated with his retirement home. Because he was surrounded by caring people, Mr. B continued to live with dignity and respect despite his progressively limited ability to communicate and to take care of himself.

Selected Nursing Diagnoses

• Impaired verbal communication related to cognitive impairment, as evidenced by recent memory loss, confabulation and disorientation

• Impaired social interaction related to altered thought processes, as evidenced by a loss of conformity to social norms

• Bathing self-care deficit related to cognitive impairment, as evidenced by a failure to perform personal hygiene activities without reminders

• Dressing self-care deficit related to cognitive impairment, as evidenced by a need for assistance in selecting appropriate clothing

The behaviors associated with dementia reflect the brain tissue alterations that are taking place (Table 22-2). Behavioral change occurs slowly in the early and late stages of AD and rapidly in the middle stage. The three stages of AD are listed in Box 22-3.

BOX 22-3 THREE STAGES OF ALZHEIMER DISEASE

Stage I: Mild—2 to 4 average years duration

• Repeats words or action

• Has trouble remembering names and common objects

• Gets lost easily

• Loses things

• Beginning problems in activities of daily living (ADLs)

• Subtle personality changes

• Shows lack of interest in usual activities

Stage II: Moderate—2 to 10 average years duration

• Obvious memory problems

• Gets confused about recent events

• Decreased ability to perform ADLs

• Argues easily

• Seems anxious and depressed

• Paces

• Noticeable behavioral difficulties

• Close supervision needed

Stage III: Severe—1 to 3 average years duration

• Fragmented memory

• No recognition of familiar people

• No recognition of self in mirror

• Uses words improperly

• Depends on others for basic ADLs

• Reduced mobility

TABLE 22-2

ASSOCIATION OF AREAS OF BRAIN PATHOLOGY WITH BEHAVIORAL CHANGES IN DEMENTIA

ANATOMICAL STRUCTURE	FUNCTION	DYSFUNCTION
Occipital lobe	Visual processing	Blindness, loss of depth perception, color agnosia (lack of recognition), persistent after-images
Frontal lobe	Organization of words into fluent speech	Difficulty using “little words” (e.g., in, on, he, she, or); changes in personality, judgment, and behavior
Parietal lobe	Association area for integrating sensory input	Alexia (inability to read), agraphia (inability to write), neglect syndrome, inability to perceive pain, agnosia, apraxia, aphasia, visual-spatial disturbances, loss of executive functions, psychosis
Temporal lobe	Recognition and comprehension of sensory input; hearing; memory consolidation; association of memory, thought, perception, and emotion	Agnosia, apraxia, aphasia, visual-spatial disturbances, loss of executive functions, disorientation in space and time, psychosis, memory loss, misinterpretation of emotional events, misinterpretation of relationships
Limbic system	Emotions, storage of short-term memory, mood	Memory dysfunction, no affective dimension to memory, apathy, unstable affect, personality changes, poor learning ability, memory loss

Cognitive changes are related to the stressors that interfere with the functioning of the cerebral cortex and the hippocampus. Other areas of the brain also are affected, which is one reason for performing a complete medical and neurological examination.

Another reason is that although dementia is often irreversible, progression may sometimes be stopped or slowed by identifying the stressor and treating the underlying dysfunction. For example, the treatment of hypertension may prevent a further occurrence of one large or many small brain hemorrhages, which are possible causes of vascular dementia.

Depression in the elderly is often misinterpreted as dementia and therefore is not treated appropriately. Pseudodementia is a cognitive impairment that occurs secondary to a functional psychiatric disorder such as depression and is characterized by lapses in memory and judgment, poor concentration, and seemingly diminished intellectual capacity. This condition is reversible with appropriate treatment of the depression.

Depression associated with AD is among the most common mood disorders of older adults. Aggression in patients with dementia is strongly linked to the presence of depressive symptoms. Appropriate treatment of the depression may be a way of preventing and managing the physically aggressive behavior. AD behaviors related to delirium, dementia, and depression are compared in Table 22-3.

TABLE 22-3

COMPARISON OF DELIRIUM, DEPRESSION, AND DEMENTIA

PARAMETER	DELIRIUM	DEPRESSION	DEMENTIA
Onset	Rapid (hours to days)	Rapid (weeks to months)	Gradual (years)
Course	Wide fluctuations; may continue for weeks if cause is not found	May be self-limited or may become chronic without treatment	Chronic; slow but continuous decline
Level of consciousness	Fluctuates from hyperalert to difficult to arouse	Normal	Normal
Orientation	Patient is disoriented, confused	Patient may seem disoriented	Patient is disoriented, confused
Affect	Fluctuating	Sad, depressed, worried, guilty	Labile; apathetic in later stages
Attention	Always impaired	Difficulty concentrating; patient may check and recheck all actions	May be intact; patient may focus on one thing for long periods
Sleep	Always disturbed	Disturbed; excess sleeping or insomnia, especially early-morning waking	Usually normal
Behavior	Agitated, restless	Patient may be fatigued, apathetic; may occasionally be agitated	Patient may be agitated or apathetic; may wander
Speech	Sparse or rapid; patient may be incoherent	Flat, sparse, may have outbursts; understandable	Sparse or rapid; repetitive; patient may be incoherent
Memory	Impaired, especially for recent events	Varies day to day; slow recall; often short-term deficit	Impaired, especially for recent events
Cognition	Disordered reasoning	May seem impaired	Disordered reasoning and calculation
Thought content	Incoherent, confused, delusional, stereotyped	Negative, hypochondriac, thoughts of death, paranoid	Disorganized, rich in content, delusional, paranoid
Perception	Misinterpretations, illusions, hallucinations	Distorted; patient may have auditory hallucinations; negative interpretation of people and events	No change
Judgment	Poor	Poor	Poor; socially inappropriate behavior
Insight	May be present in lucid moments	May be impaired	Absent
Performance on mental status examinations	Poor but variable; improves during lucid moments and with recovery	Memory impaired; calculation, drawing, and following directions usually not impaired; frequent “I don’t know” answers	Consistently poor; progressively worsens; patient attempts to answer all questions

Critical Reasoning

Elderly adults with depression are often misdiagnosed as having dementia; the diagnosis of delirium is often missed too. What nursing observations help determine whether a patient’s mental disorder is primarily affective or cognitive, and how would this affect treatment?

A common behavior related to dementia is disorientation. Time orientation is usually affected first, then place, and finally person. This can be distressing to the patient, who may be aware of this difficulty and embarrassed or frightened by it. This is particularly true if the person’s mental acuity fluctuates. In these instances the person is aware, during clear periods, of the confusion and disorientation experienced at other times.

Memory loss is another prominent characteristic of dementia. Those with declining memory are often not fully aware of their deficits in activities of daily living (ADLs). A mathematically based memory assessment, the MCI Screen, detects early signs of memory impairment caused by AD and related disorders. The MCI Screen helps justify the importance of regular memory assessments in people older than 65 years of age who have no previous diagnosis of memory disorders.

Memory includes several aspects:

• Remote memory: recall of events, information, and people from the distant past

• Recent memory: recall of events, information, and people from the past week or so

• Immediate memory: recall of information or data to which a person was just exposed

All of these are evaluated during a mental status examination (see Chapter 6).

In the last clinical example, Mr. B had trouble remembering the three objects he had heard named 5 minutes before and what he had eaten for lunch, but he gave accurate dates for significant events earlier in his life. Most aging people dwell on the past, but people with recent memory loss have difficulty shifting to the present and at advanced stages may seem to live in the past. This was demonstrated by Mr. B’s misidentification of his grandson and his daughter-in-law.

Another behavior related to memory loss is confabulation. Confabulation is a confused person’s tendency to make up a response to a question when unable to remember the answer. For instance, when Mr. B was asked whether he knew one of the female residents of the home, he replied, “Of course I know her. I used to play gin with her husband.” Actually, the woman’s husband had been dead for many years, and Mr. B had never met him.

Confabulation should not be viewed as lying or as an attempt to deceive but rather as a way of trying to save face in an embarrassing situation. Mr. B is aware that he should know the answer to the question and gives an answer that seems reasonable, not entirely disbelieving it himself.

It is not unlike the situation in which a person meets an acquaintance and cannot recall the other’s name or where they met. The person acts as if these facts are remembered, hoping that the other will offer clues about their identity. Denial of memory loss also may be related to the effect of dementia on the cognitive abilities needed for awareness of the problem.

As AD progresses, patients often develop aphasia, apraxia, agnosia, and amnesia:

• Aphasia is difficulty finding the right word.

• Apraxia is the inability to perform familiar skilled activities.

• Agnosia is difficulty in recognizing well-known objects, including people.

• Amnesia is significant memory loss in the absence of clouded consciousness or other cognitive symptoms.

These behaviors are related to the effect of the illness on the temporal-parietal-occipital association cortex.

Vocabulary and general information may be less affected by dementia until its late stages, and recall depends on when the information was learned. Facts learned early in life may be recalled well, whereas those learned recently may be quickly forgotten, as seen by Mr. B’s performance in listing the last 10 presidents.

Patients with dementia may have disturbed sleep, which can worsen memory complaints. They can have labile mood swings, particularly if the limbic system has been affected by the disease process. Some deterioration in social skills may be present as well.

Impulsive sexual advances may occur, reflecting decreased inhibition and impaired judgment as well as deterioration in the limbic system. Often this behavior is an attempt to establish interpersonal contact and is a way of asking for caring from others. It is also a way of reinforcing an important part of the person’s identity—a part that becomes less secure as mental functioning declines.

Alterations in sexual functioning associated with AD cause great concern for patients and their partners. Loss of erection ability is a common problem among men with AD, and it is uncertain whether this is physiological or psychological in origin. However, often both the patient and the sexual partner can benefit from continued sexual intimacy.

Restlessness and agitation are other behaviors that occur with dementia. Extreme agitation may occur at night, a phenomenon known as sundowning syndrome. Sundowning syndrome probably results from tiredness at the end of the day combined with fewer orienting stimuli at night, such as planned activities, meals, and contact with people.

Critical Reasoning

Based on your understanding of sundowning syndrome, describe nursing interventions that would decrease the severity of this problem in patients with dementia at home, in the hospital, or in the nursing home.

Agitation can be caused by physical and medical problems, environmental stresses, sleep problems, and psychiatric disorders. Each should be carefully evaluated and treated. Disorientation can result in fear and agitation in individuals with cognitive impairment.

QUALITY AND SAFETY ALERT

• Behavior that becomes extremely agitated is called a catastrophic reaction and is a medical emergency.

The following are precipitating factors related to catastrophic reactions:

• A change in cognitive status that results in difficulty organizing and interpreting information, sensory or cognitive overload, or misinterpretation of sensory stimuli

• Side effects of medications

• Psychosocial factors that result in increased demands to remember, such as fatigue, changes in routines or caregivers, and disorienting stimuli

• Environmental factors, including environmental changes, noise, and decreased light

The term confusion is often used when referring to a person with cognitive impairment. Although widely accepted as nursing and medical jargon, this term has not been specifically defined. It is better to use specific terms when describing a patient’s behavior. Five types of disturbing behaviors characteristic of dementia are summarized in Table 22-4.

TABLE 22-4

DISTURBING BEHAVIORS CHARACTERISTIC OF DEMENTIA

BEHAVIOR	DESCRIPTION	EXAMPLES
Aggressive psychomotor behavior	An increase in gross motor movement that has the effect of harming or repelling another	Hitting, kicking, pushing, scratching, assaultiveness
Nonaggressive psychomotor behavior	An increase in gross motor movement that does not have an apparent negative effect on others but draws attention because of its repetitive nature	Restlessness, pacing, wandering
Verbally aggressive behavior	Vocalizations that have the effect of repelling others	Demanding, disruptive, manipulative behaviors; screaming; complaining; negativism
Passive behavior	A diminution of behavior—that is, a decrease in gross motor movement accompanied by apathy and a lack of interaction with the environment	Decreased activity, loss of interest, apathy, withdrawal
Functionally impaired behavior	Loss of ability to perform self-care, the expression of which may be aversive and burdensome	Vegetative behaviors, incontinence, poor personal hygiene

Some people with maladaptive cognitive responses function at a level that is lower than would be expected on the basis of objective measurements of their impairment. This functional deficit is called excess disability.

This problem adds to the frustration of the patient and to the burden placed on caregivers. Caregivers may contribute to the development of excess disability by performing activities for the patient rather than coaching and assisting when needed. Functional abilities are lost more rapidly as the patient becomes more passive in self-care routines.

Patients with a cognitive impairment are often referred to a clinical psychologist for psychological testing. This referral should be made only for a specific purpose, because the testing is time-consuming, expensive, and tiring for the patient. Reasons for psychological testing include measuring the extent of the disability, identifying the stressors causing the disruption, understanding the dynamics of the problem, developing guidelines for therapeutic intervention, and obtaining a prognosis for recovery.

Behaviors Associated with Traumatic Brain Injury

Traumatic brain injury, often referred to as TBI, is a disruption of normal brain function that occurs when the skull is struck, suddenly thrust out of position, or penetrated. Most often it is an acute event similar to other injuries. But it differs in important ways from other injuries. Brain injury can affect all aspects of a person’s life, including personality (U.S. Dept. VA/DoD 2009; SAMHSA, 2010; Reeves and Panguluri, 2011).

No two brain injuries are alike, and each injury manifests in a different way. Symptoms may appear right away, or they may not be present until days, weeks, or months after the injury. The person may not even realize that a TBI has occurred.

The initial trauma tears, shears, or destroys brain tissue. These effects cause secondary injury in the brain including internal bleeding, swelling, oxygen deprivation, and neurochemical changes leading to cell death. A TBI can affect a single, specific region of the brain (focal injury), be distributed throughout the brain (diffuse injury), or both.

On average, an estimated 1.7 million TBIs occur each year in the United States; 52,000 of those experiencing TBI die, 275,000 are hospitalized, and 1.365 million—almost 80%—are treated and released from emergency departments. In every age group, TBI rates are higher for males than for females. Among the age groups that have the highest proportions of TBI are adolescents (aged 15-19 years) and older adults (≥75 years). Sports-related TBIs alone are estimated at between 1.6 million and 3.8 million each year.

For service members in Iraq or Afghanistan, the main TBI risk has been from an improvised explosive device (IED) such as a roadside bomb. Helmets and body armor provide some protection against penetrating head injury and, to a lesser extent, against head-impact events. However, the brain remains vulnerable to the effects of blast waves from IEDs. Gunshot wounds as well as combat- or training-related falls and motor vehicle crashes are other causes of service-related TBI (Snell and Halter, 2010). See Chapter 39 for a discussion of the mental health needs of the military and their families.

TBI is classified into three categories: mild, moderate and severe.

• Mild—A brain injury can be classified as mild if loss of consciousness and/or confusion and disorientation lasts less than 30 minutes. About 75% of all TBIs are mild. Concussion is often used interchangeably with mild TBI. Whereas magnetic resonance imaging (MRI) and computed tomography (CT) scans are often normal, the individual has cognitive problems such as headache, difficulty thinking, memory problems, attention deficits, mood swings, and frustration. These injuries are often overlooked and can be difficult to diagnose.

• Moderate—Moderate brain injury is related to loss of consciousness for more than 30 minutes and less than 24 hours. There may be amnesia for 1 to 7 days related to the injury. Brain imaging may or may not reveal abnormalities.

• Severe—Severe brain injury is associated with loss of consciousness for longer than 24 hours. There is often objective evidence of brain injury on brain scans and neurological examinations. The deficits range from impairment of higher-level cognitive functions to comatose states. Survivors may have limited function of arms or legs, abnormal speech or language, loss of thinking ability, and emotional problems.

The common effects of TBI are listed in Box 22-4. The level and duration of the effects vary from person to person. These effects can be confused with symptoms of other psychiatric disorders.

BOX 22-4 COMMON EFFECTS OF TRAUMATIC BRAIN INJURY (TBI)

Physical Problems