Final Exam, Dementia-Alzheimer's Disease complete study review solution

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Final Exam, Dementia/Alzheimer's Disease complete study review solution How is dementia characterized? - Syndrome characterized by dysfunction or loss of -Memory -Orientation -Attention -Language -Judgment -Reasoning What are additional characteristics that can manifest from dementia? - Other characteristics that can manifest -Personality changes Behavioral problems such as -Agitation -Delusions -Hallucinations What problems can arise from dementia, when do drs diagnose it? - Problems disrupt individual's -Work -Social responsibilities -Family responsibilities Physicians usually diagnose when two or more brain functions are significantly impaired. (such as memory loss or language skills are sig impaired)

Statistics of dementia - Not a normal part of aging Affects 15% of older Americans ~100 causes of dementia >60% of patients with dementia have Alzheimer's disease (AD). Half of the patients in most long-term care facilities have dementia. Dementia is due to treatable and non-treatable conditions, the two most common causes are? - Due to treatable and nontreatable conditions Two most common causes: 1.)Neurodegenerative conditions (AD) (60% to 80% of cases) 2.) Vascular disorders, also called multiinfarct dementia is a loss of cognitive function resulting from ischemic, ishemic hypoxic, or hemarrhagic brain lesions caused by CVD. Decreased blood supply to brain. VD can be caused by a single stroke (infarct) or by multiple strokes. Describe treatable conditions? - -The treatable conditions are potentially reversible. Initially these conditions may be reversible. However, with prolonged exposure or disease, irreversible changes may occur. ie) folate deficiency, vitamin b deficiency etc see box 60-2 Describe Vascular dementia - Vascular dementia Loss of cognitive function due to brain lesions caused by cardiovascular disease Ischemic lesions Ischemic-hypoxic lesions Hemorrhagic brain lesions Predisposed risks of dementia - Smoking Cardiac dysrhythmias Hypertension Hypercholesterolemia Diabetes mellitus Coronary artery disease Metabolic syndrome What are the intital symptoms seen in dementia? often reported by whom? - Initial symptoms are related to changes in

cognitive function. -Family members often report to doctor -Memory loss -Mild disorientation -Trouble with words and/or numbers **Often it is a family member, in particular the spouse, who reports the patient's declining memory to the health care provider. Thoroughly evaluate patient history, what 3 areas specifically? - Medical Neurological Psychological Physical examination to rule out other medical conditions include screening for? - Screen for Cobalamin (vitamin B12) deficiencies Hypothyroidism Possibly neurosyphilis Mild cognitive impairment what does that pt look like? - -May be able to compensate, making diagnoses difficult American Academy of Neurology recommends =Cognitive evaluation =Ongoing clinical monitoring due to increased risk of developing dementia Type of Mental status testing? - Mental status testing Mini-Mental State Examination Commonly used tool Assesses cognitive functioning -can be hard bc pts with mild dementia will try to compensate Dementia often gets mistaken for what? and vice versa? - Depression often mistaken for dementia and vice versa Manifestations of depression, especially in older adults -Sadness -Difficulty thinking and concentrating -Fatigue

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-Apathy -Feelings of despair -Inactivity Describe servere depression, and related to demetia? - -When the depression is severe, poor concentration and attention may result, causing memory and functional impairment. -When dementia and depression occur together (which may occur in up to 40% of patients with dementia), the intellectual deterioration can be extreme. Vascular brain lesions can be seen by neuroimaging such as,? - Computed tomography (CT) Magnetic resonance imaging (MRI) To characterize central nervous system (CNS) changes: Single-photon emission computed tomography (SPECT) Positron emission tomography (PET) **these tools are not routinly used as an intital diagnosis of dementia, generally used as evaluation Describe Mild cognitive impairment? - -State of cognitive and functional ability below defined norms that does not meet criteria for dementia -Memory impaired but function normally *Symptoms are not severe enough to interfere with activities of daily living. To the casual observer, an individual with MCI may seem fairly normal. However, the person with MCI is often aware of a significant change in memory, and family members may observe changes in the individual's abilities. Characteristics of mild cognitive impairment? - Memory complaint Abnormal memory for age Intact activities of daily living Normal general cognitive functioning -freq misplaces things -freq forgets peoples names -begins to forgot important events, appts -may forget recent events or newly learned info -worries about mem loss, friends/fam notice lag

Mild cognitive impairment affects how many? what age? - 10% to 20% of individuals >65 years old have MCI. 15% of those with MCI will develop dementia. What is the treatment for MCI? - Presently no widely accepted guidelines for treatment Insufficient evidence Research is being conducted. Primary treatment consists of ongoing monitoring. -Observe for warning signs *Research is being conducted to determine whether patients with MCI would benefit from the medications used in AD (e.g., acetylcholinesterase inhibitors). Alzheimer's Disease - -Chronic, progressive, degenerative disease of the brain Most common form of dementia ~5.3 million Americans suffer from AD.It is estimated that 5% of people ages 65 to 74, and nearly 50% of those over age 85, have AD. -Ultimately, the disease is fatal, with death typically occurring 4 to 6 years after diagnosis, although some patients live for 20 years. AD incidence is slightly higher in? - -The incidence of AD is slightly higher in African Americans and Hispanic Americans. -AD has been associated with lower socioeconomic status and educational level and poor access to health care. -Women are more likely than men to develop AD, primarily because they live longer. Cause of AD? Risk factors? - Exact cause is unknown. Age is most important risk factor. Familial Alzheimer's disease -Persons in whom a clear pattern of inheritance within a family is established have familial Alzheimer's disease (FAD). -FAD is associated with earlier onset (before 60 years of age) and a more rapid disease course.

What changes in the brain structure occure bc of AD? - Changes in brain structure and function -Amyloid plaques -Neurofibrillary tangles -Loss of connections between cells and cell death Describe brain plaques in AD? - People develop some plaques in their brain tissue. In AD plaque is greater in certain parts. Clusters of insoluble plaque β -amyloid, other proteins, remnants of neurons, non-nerve cells, and other cells Where do the plaques develop? - Where plaques develop in the parts of the brain used for Memory & Cognitive function which occur in the Hippocampus -Eventually develops in the cerebral cortex esp areas responsible for language and reasoning What are Neurofibrillary tangles? main component? - Neurofibrillary tangles Abnormal collections of twisted protein threads inside nerve cells Main component is a protein called tau. -Tau proteins in the CNS are involved in providing support for intracellular structure through their support of microtubules. -Tau proteins hold the microtubules together, like railroad ties hold railroad tracks together. In AD, the tau protein is altered, and as a result, the microtubules twist together in a helical fashion. Significant in final state of AD? Causes what? - -Gradual loss of connections between neurons Leads to damage and then death of neurons Affected parts of brain shrink. Brain atrophy

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How do reserachers think that inflammation is linked to AD? - Researchers interested in link between inflammation and AD -Theory suggests that formation of free radicals damages neurons loss of function -Oxidative damage leads to inflammation. Early signs of Alzheimer's disease - -Memory loss that affects job skills -Difficulty performing familiar tasks -Problems with language -Disorientation to time and place - Poor or ↓ judgment -Problems with abstract thinking -Misplacing things -Changes in mood or behavior -Changes in personality -Loss of initiative How is AD categorized? Progression? - Categorized similarly to those for dementia -Mild -Moderate -Late Progression is variable from person to person and ranges from 3 to 20 years. How does AD present? - -Initial sign is subtle deterioration in memory. -Inevitably progresses to more profound memory loss -Manifestations easier to recognize when family member or patient seeks medical help. Behavior of patient with AD? - -Recent events and new information cannot be recalled. -Behavioral manifestations are not intentional or controllable because of ongoing loss of neurons. -Some develop psychotic manifestations. *Behavioral manifestations of AD (e.g., agitation, aggression) result from changes that take place within the brain. They are neither intentional nor controllable by the individual with the disease.

As AD progresses, the patients are more likely to exhibit? - In AD that has progressed, -Dysphasia ( difficluty swallowing) -Apraxia (inability to execute learned purposeful movements) -Visual agnosia (inability to identify objects by sight) -Dysgraphia (inability to write) -Some long-term memory loss -Wandering Late Stage AD - Late stages -Long-term memory loss -Unable to communicate -Cannot perform activities of daily living (ADLs) -Patient may be unresponsive and incontinent, requiring total care. What type of diagnosis is AD? - -Diagnosis of exclusion No single clinical test -Made once all other possible conditions causing cognitive impairment have been ruled out What is involved in a Comprehensive patient evaluation regarding AD? - - Complete health history -Physical examination -Neurologic assessment -Mental status assessment -Laboratory tests What allows for monitoring in early stages and treatment response? - Brain imaging tests CT MRI SPECT PET -**A CT or an MRI scan may show brain atrophy and enlarged ventricles in the later stages of the disease, although this finding occurs in other diseases and can also be seen in persons without cognitive impairment.

SPECT, magnetic resonance spectroscopy (MRS), and PET allow for detection of changes early in the disease, as well as monitoring of treatment response. {See next slide for figure.} What is Neuropsychologic testing? - Neuropsychologic testing can help document degree of cognitive impairment. Mini-Mental State Examination (MMSE) Also used to determine a baseline from which to evaluate change over time Collaberation management of AD aimed at? - No cure Collaborative management aimed at -Improving or controlling decline in cognition -Controlling undesirable behavioral manifestations -Providing care for the caregiver How are Cholinesterase inhibitors used? - Cholinesterase inhibitors -Used to treat mild and moderate dementia -Block cholinesterase, enzyme responsible for breaking down acetylcholine -Improve or stabilize cognitive decline but do not cure or reverse Cholinesterase inhibitors include - donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Rivastigmine is available as a patch. Memantine (Namenda) how does this drug work? - -protects nerve cells against excess amounts of glutamate. *The attachment of glutamate to N-methyl-D-aspartate (NMDA) receptors permits calcium to flow freely into the cell, which in turn may lead to cell degeneration. Memantine may prevent this destructive sequence by blocking the action of glutamate. How/why are depression drugs used? - Depression often treated with selective serotonin reuptake inhibitors -May help with sleep problems -Antiseizure drugs

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-Manage behavioral problems -Stabilize mood SSRI? Antidepressant? Antiseizure? - -SSRIs include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). -The antidepressant trazodone (Desyrel) may help with problems related to sleep. However, this agent may result in hypotension. -Antiseizure drugs have been shown to increase the risk of death in elderly dementia patients. The FDA has warned that antipsychotics are not indicated for the treatment of dementia-related psychosis. However, the warning does not mean that the drugs cannot be used for these patients with dementia. Subjective data to be taken in AD evaluation - Subjective data -Past health history, repeated head trauma, stroke, exposure to metals (mercury,aluminum) prev CNS infection, fam history of dementia) -Medications, use of any drug to decrease symptoms (tranquilizers, hypnotics, antidepressants, antipsych) (Functional Health Pattern) -Health perception, health mtg., positive fam history, emotional lability) -Activity/exercise- poor personal hygiene, gait instability, weakness, inability to preform ADL's -Nutritional state, anorexic, malnourished, weightloss, -Eliminating properly — incontinence Sleep-Rest, daytime napping, freq night wakings -Cognitive-Perceptual- forgetfulness, inabiltiy to cope with complex situations, diff with prob solving (early sign) depression, withdrawl Objective Data to be taken in assessment - General: Disheveled appearance, agitation Neurologic -Early, loss of recent memory, disoriented to day/time -Middle,agitation, impaired ability to rec close fam member, lossing speak, muscle control -Late, inabiltiy to do self care, incontinence, inmobile, flexor posturing Useful questions for the patient and informant are? - "When did you first notice the memory loss?" and "How has the memory loss progressed since then?"

Possible NDX for AD - Impaired memory Self-care deficit Risk for injury Grief Wandering Overall goals for AD patient - -Maintain functional ability as long as possible. -Maintain safe environment. -Personal care needs met -Dignity maintained Overall goals for caregiver of a patient - -Reduce caregiver stress. -Maintain personal, emotional, and physical health. -Cope with long-term effects associated with caregiving. What are the nursing implementations of AD - -No known method to reduce risk of AD -Antioxidants may be of benefit. -Promote safety in physical activities and driving. -Recognize and treat depression. -Genetic testing not performed on a regular basis Warning signs of AD - Early recognition and treatment important Nurse should inform patients and family regarding early warning signs. (table 60- 6) -Memory loss that affects job skills -Diff preforming fam tasks -Problems with language -Disorientation to time and place -Poor or decreased judgment, sweater in the summer -Problems with abstract thinking, basic calculations -Misplacing things, eating utensil in clothes drawer -Changes in mood/behavior -Changes in personality -Loss of iniative

How might a pt/family respond to a diagnosis of AD? - Diagnosis traumatic for patient and family Patient often responds with -Depression -Denial -Anxiety and fear -Isolation **In the early stages of AD, patients are often aware that their memory is faulty and do things to cover up or mask the problem. What Happens Next? is a booklet specifically for people dealing with the beginning stages of dementia. Website. Acute nursing intervention for AD - -Nurse should assess for depression and suicidal ideation. -Counseling and antidepressants may be indicated. -Family members may be in denial, delaying critical early care. Nurses should assess family members by? - Nurse should also assess family members and their ability to cope and accept diagnosis. -Ongoing monitoring important -Work in collaboration with patient's caregiver. -Teach caregiver how to manage care. **An important nursing responsibility is to work collaboratively with the patient's caregiver to manage clinical manifestations effectively as they change over time. AD patients subject to other health care problems because? as a nurse you facilitate this by? - -Inability to communicate symptoms places responsibility on caregiver and health care professionals. -Hospitalization can precipitate a worsening of disease or delirium. **Patients with AD hospitalized in the acute care setting will need to be observed more closely because of concerns for safety, frequently oriented to place and time, and given reassurance. Home and LT care facility care of AD patitents involves? Nursing care is focused on? - Family members and friends care for most AD patients in their homes. -Various facilities should be evaluated. -Consider stage of AD patient when choosing.

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-Nursing care intensifies over time. **Nursing care is focused on decreasing clinical manifestations, preventing harm, and supporting the patient and caregiver throughout the disease process. Early stages of AD? - In early stages, memory aids may provide benefit. -Drugs must be taken regularly. -Drug compliance can be challenging. -Adult day care can provide -Caregiver respite -Stimulation for AD patient ** An example of a memory aid is a calendar. -Patients often develop depression during the early-stage phase. -The drugs must be taken on a regular basis. Because memory is one of the key functions to be altered in AD, adherence to drug therapy may be challenging. -During the early and middle stages of AD, the person can still benefit from stimulating activities that encourage independence and decision making in a protective environment. When is a LT care facility a good idea? - -Demands on caregiver can exceed resources, and total care is needed. -Person may need to be placed in a long-term care facility. -Special units for AD patients are growing in long-term care facilities. Emphasis is on safety. **For example, many facilities have designated areas that allow the patient to walk freely within the unit while the unit is secured, so the patient cannot wander outside of it. Behavioral problems in AD? - Occur in 90% of AD patients These problems include -Repetitiveness -Delusions -Illusions -Hallucinations -Agitation -Aggression -Altered sleep patterns -Wandering

-Resisting care Characteristics of AD behavior problems? - -Behavior is unpredictable. -Can be challenging for caregiver -Behaviors are not intentional and are difficult to control. -Often lead to placement in institutional settings Are an AD's patient's way of responding to precipitating factor? - Pain Frustration Temperature extremes Anxiety As a nurse how do we handle behavioral problems in AD patient? - Assess patient's -Physical status -Environment -Reassure patient about his or her safety. **When these behaviors become problematic, you must plan interventions carefully. Nursing strategies to address difficult behaviors - -Redirection -Distraction -Reassurance Do not threaten or restrain patient if frustrated. ** Use reality orientation to orient to time, place, and person. Do not ask the confused or agitated patient challenging "why" questions. -Ways to distract the agitated patient may include providing snacks, taking a car ride, sitting on a porch swing or rocker, listening to favorite music, watching videotapes, looking at family photographs, or walking. -Use of repetitive activities, songs, poems, music, massage, aromas, or a favorite object can be soothing to patients. What is sun-downing? How do you handle as a nurse? - -AD patients can experience sundowning. -Specific type of agitation -Patient becomes more confused and agitated in late afternoon or evening. Cause is unclear.

-Remain calm and avoid confrontation. **Sundowning behaviors commonly exhibited include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Safety risks to AD patients? - Risks -Injury from falls -Ingesting dangerous substances -Wandering -Injury to others and self -Fire or burns -Inability to respond to crisis How can nurses help decrease safety risks to AD patients? - Nurse can help caregiver in assessing home environment for safety risks. Wandering is major concern. AD patient can register with Safe Return. **Wandering may be related to loss of memory or to side effects of drugs, or it may be an expression of a physical or emotional need, restlessness, curiosity, or stimuli that trigger memories of earlier routines. -The Safe Return program includes identification products (e.g., bracelet, necklace, wallet cards), a national photo/information database, a 24-hour toll- free emergency crisis line, local chapter support, and wandering behavior education and training for caregivers and families. Pain mtg in AD patient - -Pain should be recognized and treated promptly. -Monitor patient's response. -Patients can have difficulty communicating complaints. -May exhibit changes in behavior -Because of difficulties with oral and written language associated with AD, patients may have difficulty expressing physical complaints, including pain. Trouble swallowing can lead to? - Undernutrition problem in middle and late stages Loss of interest in food Decreased ability to self-feed Co-morbid conditions

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-In long-term care facilities, inadequate assistance with feeding may add to the problem. Interventions to reduce risk of malnutrition? - When chewing and swallowing become difficult, use -Pureed food -Thickening liquids -Nutritional supplements Quiet and unhurried environment Easy-grip utensils **Distractions at mealtimes, including the television, should be avoided. Low lighting, music, and simulated nature sounds may improve eating behaviors. Tips to avoid malnutrition? - Offer liquids frequently. Finger foods may allow self-feeding. Short-term possibilities Nasogastric (NG) feedings Percutaneous endoscopic gastrostomy (PEG) tube Oral care in AD patient? - In late stages, patient will be unable to perform oral self-care. -Dental problems are likely to occur. -Patient may pocket food, adding to potential tooth decay. -Inspect mouth regularly, and provide mouth care. **Dental caries and tooth abscess can add to patient discomfort or pain and subsequently may increase agitation. Common infections in AD? - Common Urinary tract infection Pneumonia Ultimate cause of death in many AD patients Manifestations need prompt evaluation and treatment. **Because of feeding and swallowing problems, the patient with AD is at risk for aspiration pneumonia. Reduced fluid intake, prostate hyperplasia in men, poor hygiene, and urinary drainage devices (e.g., catheter) can predispose to bladder infection.

Skin care in AD pt.? - In late stages, patient are at risk for skin breakdown. Incontinence, immobility, and undernutrition Tend to rashes, areas of redness. Keep skin dry and clean. Change patient's position regularly. Urinary/incontinece problems in AD? - -Urinary and fecal incontinence during middle to late stages -Habit or behavioral retraining may ↓ epi sodes - Constipation may relate to immobility, dietary intake, ↓ fluids **The combination of aging, other health problems, and swallowing difficulties may increase the risk of complications associated with the use of mineral oil, stimulants, osmotic agents, and enemas. Caregivers SUPPORT in AD? - AD disrupts all aspects of personal and family life. Very stressful Caregivers also exhibit adverse consequences. Work with caregiver to -Assess stressors -Identify coping strategies -Find a support group -Local Alzheimer Association chapter Patient goals in AD - Patient goals -Functions at highest level of cognitive ability -Performs self-care, bathing, dressing, and toileting with assistance as needed -Experiences no injury -Uses assistive devices appropriately for ambulation support -Uses effective coping strategies to manage grief related to diagnosis of AD -Verbalizes reality of health situation -Remains in restricted area during ambulation and activity Lewy body dementia (LBD) - -Characterized by presence of Lewy bodies in brainstem and cortex Common cause of dementia Often unrecognized

Symptoms of LBD- -Parkinsonism -Hallucinations -Short-term memory loss -Unpredictable cognitive shifts -Sleep disturbances LBD con't..extrapyamidal signs include? - Dementia plus two of the following indicates a possible diagnosis: -Extrapyramidal signs such as bradykinesia, rigidity, and postural instability, but not always a tremor Fluctuating cognitive ability Hallucinations **This disease has features of both AD and Parkinson's disease, and it is imperative that a correct diagnosis be reached. Meds for LBD - LBD (cont'd) -Medications determined on an individual basis -Standard treatment plan has not been determined. -Nursing care for LBD patients relates to management of dementia. -Medications may include levodopa/carbidopa and acetylcholinesterase inhibitors. Creutzfeldt-Jakob disease (CJD) - Rare and fatal brain disorder Caused by a prion protein **A prion is a small infectious pathogen containing protein but lacking nucleic acids. The source of infection for a variant form of CJD (vCJD) is beef obtained from animals contaminated with bovine spongiform encephalopathy, which is also called mad cow disease. Earliest Symptoms of Creutzfeldt-Jakob disease (CJD) - Earliest symptoms -Memory impairment -Behavior changes Progression of CJD? - Disease progresses rapidly. Mental deterioration

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Involuntary movements Weaknesses in limbs Blindness Eventual coma No treatment -Only autopsy and examination of brain tissue can confirm the diagnosis. The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD can be detected. The nurse describes early warning signs of AD, including: - 1. Forgetting a colleague's name at a party. 2. Repeatedly misplacing car keys or a wallet. 3. Leaving a pot on the stove that boils dry and burns. 4. Having no memory of preparing a meal and forgetting to serve or eat it. ANSWER= 4. Rationale: Memory loss that affects job skills: Frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong. This type of memory loss goes beyond forgetting an assignment, a colleague's name, a deadline, or a phone number. Difficulty performing familiar tasks: It is not abnormal for most people to become distracted and to forget something (e.g., leave something on the stove too long). People with Alzheimer's disease (AD) may cook a meal but then forget not only to serve it but also that they made it. Misplacing things: For many individuals, temporarily misplacing keys, purses, or wallets is a normal albeit frustrating event. Persons with AD may put items in inappropriate places (e.g., eating utensils in A patient with Alzheimer's disease has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for the patient is to: - 1. Let the patient know what behavior is socially appropriate. 2. Assist the patient with all self-care to maintain self-esteem. 3. Maintain familiar routines of sleep, meals, drug administration, and activities. 4. At every encounter with the patient, ask the day, time, and place to promote orientation. ANSWER=3. Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

Final Exam, Dementia-Alzheimer's Disease complete study review solution

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