Feature	Dementia	Delirium	Depression
Onset	Usually insidious.	Rapid, often at night.	Often coincides with life changes. Often abrupt.
Progression	Slow.	Abrupt.	Variable, rapid to slow but may be uneven.
Duration	Years (usually 8-20).	Hours to days to weeks.	Can be several months to years, especially if not treated.
Thinking	Difficulty with abstract thinking, impaired judgment, words difficult to find.	Disorganized, distorted. Slow or accelerated incoherent speech.	Intact but with apathy, fatigue. May be indecisive. Feels sense of hopelessness. May not want to live.
Perception	Misperceptions often present. Delusions and hallucinations.	Distorted. Delusions and hallucinations.	May deny or be unaware of depression. May have feelings of guilt.
Psychomotor behavior	May pace or be hyperactive. As disease progresses, may not be able to perform tasks or movements when asked.	Variable. Can be hyperactive or hypoactive, or mixed.	Often withdrawn and hypoactive.
Sleep-wake cycle	Sleeps during day. Frequent awakenings at night. Fragmented sleep.	Disturbed sleep. Reversed sleep-wake cycle.	Disturbed, often with early morning awakening.

Dementia

Dementia is a syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may occur. Ultimately these problems result in alterations in the individual’s ability to work, fulfill social and family responsibilities, and perform activities of daily living. Dementia is often diagnosed when two or more brain functions, such as memory loss or language skills, are significantly impaired.

Fifteen percent of older Americans have dementia. As the average life span increases, the number of those affected with dementia is growing. There are about 100 causes of dementia, with about 60% to 80% of the patients with dementia having a diagnosis of Alzheimer’s disease (AD) (Fig. 60-1). In the United States, about half of all patients in long-term care facilities have AD or a related dementia.¹

eNursing Care Plan 60-1 Patient With Alzheimer’s Disease

Nursing Diagnosis*

Impaired memory related to effects of dementia as evidenced by loss of memory, distractibility, and inappropriate thinking

Patient Goal

Functions at highest level of cognitive ability

Outcomes (NOC)	Interventions (NIC) and Rationales
Cognition	Dementia Management
• Communication clear and appropriate for age _____ • Comprehension of the meaning of situations _____ • Attentiveness _____ • Cognitive orientation _____ • Immediate memory _____ • Recent memory _____ • Remote memory _____ • Information processing _____ • Appropriate decision making _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Determine type and extent of cognitive deficit(s), using standardized assessment tool, to establish baseline function. • Include family members in planning, providing, and evaluating care to the extent desired to plan appropriate and consistent interventions. • Discuss with family members and friends how best to interact with patient to maintain consistency. • Identify usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care to maintain familiar routines. • Give one simple direction at a time to decrease confusion and frustration. • Use distraction, rather than confrontation, to manage behavior, which will decrease anxiety. • Avoid unfamiliar situations when possible (e.g., room changes and appointments without familiar people present) to avoid anxiety and confusion. • Limit number of choices patient has to make so as not to cause anxiety. Reality Orientation • Stimulate memory by repeating patient’s last expressed thought. • Inform patient of person, place, and time to promote memory and reduce confusion. • Avoid frustrating patient by quizzing with orientation questions that cannot be answered. • Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.

Nursing Diagnosis

Self-neglect related to memory deficit, cognitive impairment, and neuromuscular impairment as evidenced by inability to independently and appropriately bathe, dress, toilet, or feed self

Patient Goal

Performs basic personal care activities of daily living (ADL)s including bathing, dressing, feeding, and toileting by self or with assistance as needed.

Outcomes (NOC)	Interventions (NIC) and Rationales
Self-Care: Activities of Daily Living (ADL)	Self-Care Assistance
• Eating _____ • Dressing _____ • Toileting _____ • Bathing _____ • Grooming _____ • Hygiene _____ • Oral hygiene _____ • Walking _____ • Wheelchair mobility _____ • Transfer performance _____ • Positions self_____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Monitor patient’s ability for independent self-care to plan appropriate interventions specific to patient’s unique problems. • Use consistent repetition of health routines as a means of establishing them as memory loss impairs patient’s ability to plan and complete specific sequential activities. • Assist patient in accepting dependency needs to ensure all needs are met. • Teach patient/caregivers to encourage independence and to intervene only when patient is unable to perform to promote independence. Self-Care Assistance: Bathing/Hygiene • Provide desired personal articles (e.g., deodorant, toothbrush, bath soap, shampoo, lotion) to enhance memory and provide care. • Facilitate patient’s bathing self to facilitate independence and provide appropriate help in hygiene. Self-Care Assistance: Dressing/Grooming • Provide patient’s clothes in accessible area (e.g., at bedside) to enhance memory and independence. • Be available for assistance in dressing to facilitate independence and provide appropriate help in dressing. Self-Care Assistance: Feeding • Fix food on tray, as necessary, such as cutting meat or peeling an egg, to facilitate handing of food. • Provide adaptive devices to facilitate patient’s feeding self (e.g., long handles, handle with large circumference, or small strap on utensils). • Provide frequent cueing and close supervisions as patient may forget to eat. Self-Care Assistance: Toileting • Assist patient to toilet/commode/bedpan/fracture pan/urinal at specified intervals to promote regularity. • Facilitate toilet hygiene after completion of elimination to prevent discomfort and skin excoriation. • Institute a toileting schedule to promote regular toileting and avoid toileting accidents.

Nursing Diagnosis

Risk for injury related to impaired judgment, gait instability, muscle weakness, and sensory/perceptual alteration

Patient Goals

1. Experiences no injury

2. Uses assistive devices appropriately for ambulation support

Outcomes (NOC)	Interventions (NIC) and Rationales
Fall Prevention Behavior (Caregiver)	Fall Prevention
• Places barriers to prevent falls _____ • Eliminates clutter, spills, glare from floors _____ • Uses assistive devices correctly _____ • Uses safe transfer procedure_____ • Provides assistance with mobility _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Identify cognitive or physical deficits of the patient that may increase potential falls in a particular environment to decrease or prevent occurrence of injury. • Provide assistive devices (e.g., walker) to steady gait and provide ambulation support. • Identify and remove potential dangers in environment for patient. • Ensure that patient wears shoes that fit properly, fasten securely, and have nonskid soles to provide support during ambulation. • Instruct patient to wear prescription glasses when out of bed to allow for proper vision. • Use a bed alarm to alert caregiver that individual is getting out of bed to ensure assistance as needed.

Nursing Diagnosis

Patient Goal

Remains in restricted area during ambulation and activity

Outcomes (NOC)	Interventions (NIC) and Rationales
Safe Wandering	Dementia Management
• Moves about without harming self _____ • Moves about without harming others _____ • Remains in secure area when unaccompanied _____ • Moves about only in own and public space _____ • Can be redirected from unsafe activities _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Provide space for safe pacing and wandering to prevent injury and getting lost. • Use symbols, other than written signs, to assist patient to locate room, bathroom, or other area to orient patient to environment. • Provide boundaries, such as red or yellow tape on the floor, when low-stimulus units are not available. Elopement Precautions • Familiarize patient with environment and routine to decrease anxiety. • Limit patient to a physically secure environment as needed to prevent elopement. • Provide patient with identification band to enable identification if patient becomes lost. • Provide appropriate level of supervision/surveillance to monitor patient and to allow for therapeutic actions.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 60-2 Family Caregivers

Nursing Diagnosis*

Caregiver role strain related to grieving the family member’s illness, change in role, and pressure from unrelieved caregiving as evidenced by statements about stress, inadequate resources to provide care, and worry about having to put the family member in a long-term care facility

Patient Goals

1. Seeks appropriate assistance and support to maintain caregiver role

2. Expresses satisfaction with ability to fulfill caregiver role

3. Receives periodic respite from caregiving role

Outcomes (NOC)	Interventions (NIC) and Rationales
Caregiver Stressors	Caregiver Support
• Reported stressors of caregiving _____ • Physical limitations for caregiving _____ • Psychological limitations for caregiving _____ • Role conflict _____ • Perceived lack of social support _____ • Perceived lack of health professional support _____ • Loss of personal time _____ • Conflict between work and caregiver responsibilities _____ • Perceived burden of care recipient’s progressive health problems _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	• Monitor for indicators of stress to plan interventions and support. • Act for caregiver if overburdening becomes apparent. • Acknowledge difficulties of caregiving role. • Accept expressions of negative emotion to enable open discussion of needs. • Encourage the acceptance of interdependency among family members. • Inform caregiver of health care and community resources to provide support and relief to caregiver as needed. • Acknowledge dependency of patient on caregiver to demonstrate empathy. • Teach caregiver strategies to access and maximize health care and community resources to assist caregiver with planning for long-term care. • Provide support for decisions made by caregiver (e.g., patient placement in long-term care) to allay guilt and reinforce services the patient now requires. Respite Care • Monitor endurance of caregiver to identify the need for respite care. • Coordinate volunteers for in-home services to provide respite for caregiver. • Arrange for substitute caregiver to allow caregiver relief from role.

Nursing Diagnosis

Social isolation related to diminishing social relationships, behavioral problems of patient with disease, and underdeveloped social support system as evidenced by feelings of abandonment and uselessness, behavior changes, and inability to make decisions or concentrate

Patient Goals

1. Expresses satisfaction with social relationships with others

2. Uses family and community support systems to relieve feelings of isolation

Outcomes (NOC)	Interventions (NIC) and Rationales
Caregiver Lifestyle Disruption	Socialization Enhancement
• Role flexibility _____ • Relationships with other family members _____ • Social interactions _____ • Social support _____ • Diversional activities _____ • Relationships with friends _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Encourage caregiver to change environment, such as going outside for walks or out to movies. • Encourage enhanced involvement in already established relationships to develop care alternatives. • Encourage social and community activities to decrease social isolation. Family Support • Arrange for ongoing respite care to enable caregiver to continue with important activities and social contacts. • Provide opportunities for peer group support (e.g., Alzheimer’s Association, American Heart Association) as these groups can meet socialization, recreational, and educational needs of caregiver. Support System Enhancement • Determine adequacy of existing social networks to evaluate need for change. • Involve family/significant others/friends in care planning to decrease isolation of caregiver.

Nursing Diagnosis

Patient Goals

1. Verbalizes decreased anxiety

2. Reports sense of control of situation

Outcomes (NOC)	Interventions (NIC) and Rationales
Caregiver Emotional Health	Coping Enhancement
• Anger _____ • Resentfulness _____ • Guilt _____ • Depression _____ • Frustration _____ • Perceived burden _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None • Certainty about future _____ • Sense of control _____ • Satisfaction with life _____ • Perceived adequacy of resources _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Appraise the impact of the patient’s life situation on roles and relationships to determine the extent of role changes required of caregiver. • Assist caregiver in developing an objective appraisal of the event so that appropriate decisions can be made. • Provide the caregiver with realistic choices about certain aspects of care. • Assist the caregiver to solve problems in a constructive manner to ensure that caregiver has skills to manage changing roles and patient status. Caregiver Support • Inform caregiver of health care and community resources to relieve anxiety related to financial insecurity. • Teach caregiver stress management techniques to control anxiety.

Nursing Diagnosis

Ineffective health maintenance related to unrelieved caregiving responsibilities, fatigue, and chronic stress as evidenced by failure to care for self

Patient Goals

1. Demonstrates appropriate health behaviors for age and gender

2. Uses health care resources to maintain health

Outcomes (NOC)	Interventions (NIC) and Rationales
Caregiver Physical Health	Risk Identification
• Physical fitness _____ • Sleep/rest pattern _____ • Blood pressure _____ • Energy level _____ • Physical comfort _____ • Resistance to infection _____ • Perceived general health _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Institute routine risk assessment, using reliable and valid instruments, to predict need for intervention. • Review medical history and documents for evidence of existing or previous medical and nursing diagnoses to determine if the problem is present and to plan appropriate interventions. • Initiate referrals to health care personnel and/or agencies for access to long-term support. Caregiver Support • Teach caregiver strategies to access and maximize health care and community resources for personal health and well-being. • Teach caregiver health care maintenance strategies to sustain own physical and mental health and support caregiver in setting limits and taking care of self to avoid increasing the complexity of the caregiving situation.

^*Nursing diagnoses listed in order of priority.

eTABLE 60-1

MINI-MENTAL STATE EXAMINATION (MMSE)
MMSE Sample Items

Orientation to Time

“What is the date?”

Registration

“Listen carefully, I am going to say three words. You say them back after I stop. Ready? Here they are . . . HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back to me.” (Repeat up to five times, but score only the first trial.)

Naming

“What is this?” (Point to a pencil or pen.)

Reading

“Please read this and do what it says.” (Show examinee the words CLOSE YOUR EYES on the stimulus form.)

Reproduced by special permission of the Publisher, Psychological Assessment Resource, Inc., 16204 North Florida Avenue, Lutz, Fla. 33549, from the Mini-Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini-Mental, LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission from PAR, Inc. The MMSE can be purchased from PAR, Inc., by calling 813-968-3003.

Etiology and Pathophysiology

Dementia is due to both treatable and nontreatable conditions (Table 60-2). The two most common causes of dementia are neurodegenerative conditions (e.g., AD) and vascular disorders. Dementia is sometimes caused by conditions that may initially be reversible (see Table 60-2). However, with prolonged exposure or disease, irreversible changes may occur.

TABLE 60-2

CAUSES OF DEMENTIA

Type of Dementia	Cause
Neurodegenerative disorders	• Alzheimer’s disease • Dementia with Lewy bodies (DLB) • Frontotemporal lobar degeneration (FTLD) • Down syndrome • Amyotrophic lateral sclerosis (ALS) • Parkinson’s disease • Huntington’s disease
Vascular diseases	• Vascular (multiinfarct) dementia • Subarachnoid hemorrhage * • Chronic subdural hematoma *
Toxic, metabolic, or nutritional diseases	• Alcoholism • Thiamine (vitamin B₁) deficiency * • Cobalamin (vitamin B₁₂) deficiency * • Folate deficiency * • Hyperthyroidism * • Hypothyroidism *
Immunologic diseases or infections	• Multiple sclerosis • Chronic fatigue syndrome • Infections (e.g., Creutzfeldt-Jakob disease) • Acquired immunodeficiency syndrome (AIDS) • Meningitis * • Encephalitis * • Neurosyphilis * • Systemic lupus erythematosus *
Systemic diseases	• Uremic encephalopathy * • Dialysis dementia * • Hepatic encephalopathy * • Wilson’s disease
Trauma	• Head injury *
Tumors	• Brain tumors (primary)* • Metastatic tumors *
Ventricular disorders	• Hydrocephalus *
Drugs†	• Anticholinergics • phenytoin (Dilantin) • Opioids • Hypnotics • Tranquilizers • Antiparkinsonian drugs • Cardiac drugs: digoxin, methyldopa (Aldomet) • Cocaine • Heroin

^*Potentially reversible.

^†These are examples of drugs that may cause cognitive impairment that is potentially reversible.

Vascular conditions are the second most common cause of dementia.¹ Vascular dementia, also called multiinfarct dementia, is loss of cognitive function resulting from ischemic or hemorrhagic brain lesions caused by cardiovascular disease. This type of dementia is the result of decreased blood supply from narrowing and blocking of arteries that supply the brain. Vascular dementia may be caused by a single stroke (infarct) or by multiple strokes.

Nursing and Collaborative Management Dementia

In many ways, management of the patient with dementia is similar to management of the patient with AD (described later in this chapter). One form of dementia, vascular dementia, can often be prevented. Preventive measures include treatment of risk factors such as hypertension, diabetes, smoking, hypercholesterolemia, and cardiac dysrhythmias. (Stroke is discussed in Chapter 58.) Drugs that are used for patients with AD are also useful in patients with vascular dementia. Drug therapy is discussed on p. 1452 later in this chapter.

Alzheimer’s Disease

Alzheimer’s disease (AD) is a chronic, progressive, degenerative disease of the brain. It is the most common form of dementia, accounting for 60% to 80% of all cases of dementia.¹ AD is named after Alois Alzheimer, a German physician who in 1906 described changes in the brain tissue of a 55-year-old woman who had died of an unusual mental illness.

Approximately 5.2 million Americans suffer from AD. It is estimated that 11% of people age 65 and older, and nearly one third of those over age 85, have AD. Ultimately the disease is fatal, with death typically occurring 4 to 8 years after diagnosis, although some patients live for 20 years. AD is the sixth leading cause of death in the United States.¹ It is the only cause of death among the top 10 in United States that cannot be prevented or cured, or its progression even slowed. The burden of care for the patient with AD on the family, caregivers, and society is staggering. AD has often been referred to as the “long good-bye” or “death in slow motion.”

The incidence of AD is slightly higher in African Americans and Hispanic Americans than in whites. AD has been associated with lower socioeconomic status and education level and poor access to health care. Women are more likely than men to develop AD, primarily because they live longer (see the Gender Differences box).

Gender Differences

Alzheimer’s Disease and Dementia

Men	Women
• Men have a higher incidence of vascular dementia than women.	• Nearly two thirds of people with Alzheimer’s disease are women. • Women are more likely to develop Alzheimer’s disease than men, probably because they live longer. • About twice as many women as men die each year from Alzheimer’s disease.

Etiology and Pathophysiology

The exact etiology of AD is unknown, but is likely a combination of genetic and environmental factors. AD is not a normal part of aging, but as with other forms of dementia, age is the most important risk factor for developing AD. Only a small percentage of people younger than 60 years old develop AD. When AD develops in someone younger than 60 years old, it is referred to as early-onset AD. AD that becomes evident in individuals more than 60 years old is called late-onset AD (see the Genetics in Clinical Practice box).

Genetics in Clinical Practice

Alzheimer’s Disease (AD)

Genetic Basis

Early Onset (Familial) (<60 Yr Old at Onset)

• Autosomal dominant disorder.

• Various mutations in the following genes:

• Amyloid precursor protein (APP) gene on chromosome 21

• Presenilin-1 (PSEN1) gene on chromosome 14

• Presenilin-2 (PSEN2) gene on chromosome 1

Late Onset (Sporadic) (>60 Yr Old at Onset)

• Genetically more complex than early-onset form.

• Apolipoprotein E-4 (ApoE-4) allele on chromosome 19 increases the likelihood of developing AD.

• Presence of ApoE-2 allele is associated with a lower risk of AD.

Incidence

Early Onset

• Rare form of AD, accounting for <5% of cases.

• Fifty percent risk of disease for children of affected parents.

• May occur in people as young as 30 yr old.

Late Onset

• ApoE-4 is present in about 40% of people with late-onset AD. (It is present in 25%–30% of normal population.)

• Many ApoE-4-positive people do not develop AD, and many ApoE-4-negative people do.

Genetic Testing

Early Onset

• Genetic screening is available for mutations on chromosomes 1, 14, and 21.

Late Onset

• Blood test can identify which ApoE allele a person has but cannot predict who will develop disease.*

• ApoE testing is mainly used in research to identify people who may have an increased risk of developing AD.

Clinical Implications

• AD is the most common cause of dementia.

• Genetic testing and counseling for family members of patients with early-onset AD may be appropriate.

• If person tests positive for ApoE-4, it does not mean that the person will develop AD.

^*ApoE testing is useful for studying AD risk in large groups of people, but not for determining an individual’s specific risk.

Individuals with a clear pattern of inheritance within a family have familial Alzheimer’s disease (FAD). Other cases where no familial connection can be made are termed sporadic. FAD is associated with an early onset (before 60 years of age) and a more rapid disease course. In both FAD and sporadic AD, the pathogenesis of AD is similar.

Characteristic findings of AD relate to changes in the brain’s structure and function: (1) amyloid plaques, (2) neurofibrillary tangles, (3) loss of connections between neurons, and (4) neuron death. Fig. 60-2 shows the pathologic changes in AD.

FIG. 60-2 Pathologic changes in Alzheimer’s disease A, Plaque with central amyloid core *(white arrow)* next to a neurofibrillary tangle *(red arrow)* on the histologic specimen from a brain autopsy. B, Schematic representation of amyloid plaque and neurofibrillary tangle.

As part of aging, people develop some plaques in their brain tissue, but in AD more plaques appear in certain parts of the brain. These plaques consist of clusters of insoluble deposits of a protein called β-amyloid, other proteins, remnants of neurons, non-nerve cells such as microglia (cells that surround and digest damaged cells or foreign substances), and other cells such as astrocytes.

β-Amyloid is cleaved from amyloid precursor protein (APP), which is associated with the cell membrane (Fig. 60-3). The normal function of APP is unknown. In AD, plaques develop first in areas of the brain used for memory and cognitive function, including the hippocampus (a structure that is important in forming and storing short-term memories). Eventually AD attacks the cerebral cortex, especially the areas responsible for language and reasoning.