97 Dementia—alzheimer’s type

Overview/pathophysiology

Dementia is a chronic cognitive disorder that is part of a category of psychiatric disorders classified as Delirium, Dementia, and Amnestic and other Cognitive Disorders. Delirium is characterized by an acute change in cognition and consciousness that occurs over a short period of time. Dementia is characterized by multiple cognitive deficits that include impairment in memory. The dementias are also classified according to etiology: dementia of the Alzheimer’s type; vascular dementia; dementia due to other general medical conditions, such as human immunodeficiency virus (HIV) disease, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, and Creutzfeldt-Jakob disease; substance-induced persisting dementia; dementia due to multiple etiologies; and dementia not otherwise specified.

The most common form is Alzheimer’s disease (AD), a primary dementia accounting for approximately 65% of dementia cases, and it is the focus of this care plan. Although AD is age related, it does not represent the normal process of aging. It occurs with distinctive brain lesions without any known physiologic basis. The brain lesions are neurofibrillary tangles and neuritic plaques that take up space in the brain, replacing normal tissue in the cell body of the neuron. There are multiple theories to explain the occurrence of AD, including genetic transmission, a decrease in acetylcholine, beta-amyloid activity, impact of head injury, ministrokes, lack of estrogen, immunologic factors, effects of a slow-acting virus, and environmental factors.

AD affects more than 5.4 million people, making it the most common neuropsychiatric illness in older adults. The actual course of the disorder follows a predictable pattern of early, middle, and late stages, each displaying characteristic behaviors and requiring a different focus of treatment. The early stage is frequently referred to as the amnestic stage, the middle stage as the dementia stage, and the late stage as the vegetative stage. As the disease progresses, patients lose control over their bladder and bowel functions and later over swallowing. Seizures are common. Death inevitably occurs as a result of neurologic complications imposed by the brain lesions.

AD represents the clinical prototype for chronic cognitive disorders. The care required by the Alzheimer’s patient, especially in the middle and late stages of the disorder, is essentially the same care required by all dementia patients regardless of type. The cognitive symptoms of dementia involve serious memory impairment, as well as significant alterations in language and perceptual acuity and abilities to abstract, problem solve, and make appropriate judgments. Patients ultimately experience loss of all memory and aphasia (loss of meaningful verbal communication). Noncognitive behavioral symptoms can be just as profound. These include significant personality changes, purposeless movements, agitation and aggression, overreaction to situations, irritating behavior, and emotional disinhibition.

Health care setting

In the early stage of AD, care takes place in the home and primary care setting. By the end of the early stage of the disease, additional services such as home care and use of adult day care are needed to maintain the patient at home. At the end of the early stage and moving into the middle stage, the decision regarding where to place the patient begins. Patient is generally moved into residential care in the middle stage, and during the late stage, care is frequently provided in a skilled nursing facility.

Assessment

Psychiatric assessment

Involves assessment of primary and secondary psychiatric manifestations of AD and differential diagnosis from psychosis, depression, anxiety, and phobias.

Family history:

Dementing illness, psychiatric disease, neurologic disease, substance abuse.

Social history:

Education, past level of functioning per occupational history, close relationships, current living situation.

Medical history:

All past and present medical illnesses, past surgeries, past trauma especially to the head, allergies, and medication.

Psychiatric history:

Psychotic illness, depressive illness, other psychiatric illnesses, psychiatric symptoms, past and current treatments, hospitalizations, suicide ideation, violence.

Present illness:

Length of cognitive loss and degree of memory loss:

• Is short-term memory loss so significant that patient is no longer able to remember activities of daily living (ADLs)?

• Other presenting problems, physical symptoms, functional deficits, psychiatric symptoms.

• Personality changes, including low tolerance for normal frustrations, oversensitivity to remarks of others, lack of initiative, decreased attention span, diminished emotional presence, emotional lability, restlessness.

• Difficulty with word finding and comprehension; thought blocking.

Mental status examination:

Appearance, behavior, speech, mood, hallucinations, delusions, anxiety, phobias, cognition, insight and judgment, behavioral disturbances such as agitation, combativeness, screaming, catastrophic reactions.

Physical assessment

Psychomotor functioning:

Difficulty carrying out new or complex motor tasks is apparent in the early stages; difficulty carrying out activities such as dressing, eating, and walking becomes apparent in the middle stages. Unsteadiness of gait and a listing posture pose a significant risk for falls during the middle stages. In addition, marked psychomotor agitation is common. Restlessness, agitation, and aimless pacing replace normal motion.

Nutrition and elimination:

Eating difficulties may present in early stages. Patient may forget that he or she has just eaten, exhibit lax table manners, fail to know it is mealtime without prompting, experience changes in taste and appetite, express denial of hunger or need to eat, and experience weight loss. As disease progresses, patient does not respond to need for elimination, which necessitates the caregiver to plan regular bathroom breaks. Constipation and incontinence of urine and feces become problems.

Activity and rest:

Fatigue increases severity of symptoms, especially as evening approaches. Patient may reverse days and nights, with wakefulness and aimless wandering at night and disturbance of sleep rhythms. Patient may be content to sit and watch others. Main activity may be hoarding inanimate objects, hiding articles, wandering, or engaging in repetitive motions.

Hygiene:

As disease progresses, so does dependence on caregiver to meet basic hygiene needs. Appearance may be disheveled, and patient may have body odor. Clothing may be inappropriate for situation or weather conditions. Patient may forget to go to the bathroom and the steps involved in toileting.

Social assessment:

Patient may ignore rules of social conduct and exhibit inappropriate behavior. Speech may be fragmented; family roles may be altered/reversed as patient becomes more dependent.

Spiritual assessment

An assessment of patient’s faith tradition, practices, level of commitment, and connection to a faith community is critical. In the early stage of AD, the patient may have full awareness of the journey that lies ahead, and spirituality may offer support and comfort in ways that nothing else can. As the disease progresses and deficits become greater, it is difficult to assess the patient’s spiritual needs. However, because long-term memory remains intact long after the short-term memory is gone, patient may still be comforted by spiritual traditions such as worship services, prayers, and hymns that are a vivid part of his or her history. Moreover, care of the Alzheimer’s patient is so demanding that spiritual needs of the caregiver must be assessed and support provided. A faith community may provide invaluable assistance in the actual care of the patient, providing caregiver with respite and help with day-to-day activities.

Diagnostic tests

Obtaining an accurate differential diagnosis of dementia is essential. AD is basically a rule-out disorder; that is, the diagnosis is made after family history, laboratory tests, and brain imaging eliminate other disorders with similar cognitive deficits. Sources of information needed to make a differential diagnosis of dementia include a full neurologic assessment, laboratory tests to rule out metabolic factors, and family history of patient’s past behavior and symptom progression. Mini-Cog and functional assessment of ADLs provide necessary information. A computed tomography (CT) scan identifies structural deficits. Brain imaging with positron emission tomography provides the clinician with information about changes in the metabolic activity and neurochemical characteristics associated with dementia. Typically, testing of patients in the early stage of AD reveals a normal electroencephalogram, CT scan, and magnetic resonance imaging (MRI) study, and generally laboratory tests are within normal range. Comprehensive psychiatric assessment provides additional information. The use of the Functional Assessment Staging Tool (FAST) allows for staging the disease and recognizing cognitive and functional abilities and deficits of each stage of AD and making appropriate adjustments to care.

Nursing diagnosis:

Deficient knowledge

related to unfamiliarity with disease progression and care of the dementia patient

Desired Outcome: By the time the diagnosis of AD is confirmed, significant other/family relay accurate information about the course of the disease and the role they will play in the care of their loved one.

ASSESSMENT/INTERVENTIONS	RATIONALES
Assess significant other’s/family’s understanding about the disease process and expected care that will be needed for their loved one.	This assessment enables the nurse to reinforce, as needed, information about AD and correct any misunderstandings.
Provide significant other/family information about the staging of the disease and changes to expect in their loved one.	The significant other and family play integral roles in the care of their loved one. Initially, they are the informants, providing information that facilitates diagnosis; they move into role of advocate, then primary caregivers, and finally patient supporter. Staging is discussed in introductory data.
Provide written information regarding educational resources, such as The Thirty-Six Hour Day (1999) by Mace and Rabins, and support groups.	The cited book presents a compilation of family experiences with the disorder at different stages. Although there are other helpful books, this one remains the definitive resource for family caregivers. Support groups for family members offer an ongoing, practical socioeducational source, even in the early stage. They provide a safe place to explore issues such as whether or not the patient should stop driving; whether other people should be told about the diagnosis; whether the patient should wear an ID bracelet or carry a card indicating a dementia diagnosis; what the healthy spouse should do to handle the sexual desires of the affected spouse when the unaffected spouse no longer feels as though he or she has an adult relationship anymore.
Coach the family to use all their senses and past memories in talking with their loved one.	Families feel more comfortable and are more likely to continue to interact with the patient if they know that reduced animation in the patient’s face is part of the disease. Conversation may have noticeable pauses with less spontaneous speech; conversations should be short and simple. Reassuring the patient decreases overconcern about minor matters; touch continues to be important; and sharing important memories from the past helps maintain links to patient even if the response is minimal.
Teach about safety issues.	Safety issues become the responsibility of the caregiver early in the disorder. The Alzheimer’s patient needs room to pace and fails to notice scatter rugs, spills on the floor, and changes in floor elevations, which make falls more likely. Other safety concerns deal with wandering, forgetting the stove is turned on, and using toxic substances inappropriately.
Provide information about legal matters.	Decisions about durable power of attorney need to be decided in the early stage of the disease when the patient is still competent. Legal counsel may be desirable for decisions regarding financial matters.
Provide information about health care resources.	The job of the family caregiver is overwhelming. Family members need to consider use of adult day care centers and varieties of respite care, even in the early stage of the illness. Use of home health services also may be of assistance to the caregiver.
Teach strategies to deal with behavioral issues such as wandering, rummaging, incontinence, difficulty following directions, and profound memory loss.	The more knowledge the family has regarding strategies to deal with these various behaviors, the better they will be able to care for the patient.

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