Dementia / Delirium
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Group of interconnected areas that relate to emotions, learining, & memory. Help us w/ storage & recall of info.
One of 1st areas affected by Dementia. Starts here and as disease progresses it spreads outward through structure
Relay system b/w senses & cortex. Parts used for feeling alert & having sensation.
Related / involved relations, learning, emotions, memory. Is fight or flight response.
Plays role in processing emotional responses.
Gyrus (in general)
Connection b/w lymbic system w/ other parts of brain.
Aging and the human brain (Reg. / Healthy)
Occupies ____ space
____ of the cerebral sulci (grooves, furrows of brain)
____ of gyri (folds on outer portion of brain)
____ of the ventricles (contain cerebal spinal fluid)
- Weighs Less
- Occupies Less Space
- Widening of the cerebral sulci (groove, furrows of brain)
- Narrowing of gyri (folds on outer portion of brain)
- Enlargement of the ventricles (contain cerebral spinal fluid)
Billions of neurons and trillions of connections which is adequate for ____ life. This is hindered by ____ process.
Fires impulses, sends / receives messages / commmunicate through electrical impulses.
Start to notice things around age ____
Nerve cells start to ____ in number and function or facility
____ to respond
Take ____ to do things
- Start to notice things around age 50Nerve cells start to deteriorate in number and function or facility
- Slow to respond
- Forget things
- Take longer to do things
- Facilitate ____
- Facilitate ____
- Process ____
- Retain ____
- Facilitate Movement
- Facilitate Senation
- Process Information
- Retain Information (when teaching the elderly, want to teach to do something they can connect to)
Nervous System and Aging
- Recent ____ loss
- Decreased ____ sensation
- Change in perception of ____
- Altered ____
- Decreased ____
- Recent MEMORY loss (forget appt, name of somebody you just met -- this is not like putting the iron in the freezer etc.)
- Decreased TOUCH sensation
- Change in perception of PAIN
- Altered BALANCE
- Decreased COORDINATION
Cognitive Change and Aging
Cognitive changes are more offten a difference in ____ than ability.
Speed (They can do it, just not as quickly)
Priority Interventions: Communication & Altered Cognition
- Reality ____
- Recognizing ____ and ____ issues
- Interaction and ____
- Reality ORIENTATION (remind them - boards w/ date, nurses' names, clock for time; group activities - so get adequate rest; open blinds in morning)
- Recognizing STORAGE and RETRIEVAL issues (able ot learn new things - relate back to something they can relate to)
- Interaction and CONFUSION (over stimulation can cause problems, speak slowly & clearly, avoid arguments, re-orient if necessary - may need to do therapeutic fibbing)
Characteristics of Delirium
- Disoriented speech
- Clouded consciousness (out of mind)
Delirium: ____ state of confusion
Delirium: ____-term and ____
Delirium state associated with wild and moving, meaningless chatter.
Hyperactive state (usually this state)
Delirium state associated w/ quietness and withdrawn.
Do not ____ those w/ delirium b/c makes it worse, better to have someone in room.
Of people > 70 y/o: 10-20% are delirious on ____ nad 10-20% become delirious during ____.
Incidence of postop delirius amont patients > or = to 70 y/o is ____-_____% and after ER procedures is ____-____%
Potential Factors contributing to delirium:
- ____ use
- ____ stimulation
- ____ abnormalities (dehydration, over-hydration)
- ____ (UTI)
- ____ sensory input (blind, HOH, deaf - environment in hospital overstimulates)
- ____, ____, ____ disorders (O2 not circulating, kidneys not fxning)
- ____ (lower O2 carrying capability)
- Severe, uncontrolled ____
- ____ (no BM)
- ____ deficiencies (dehydration, right diet)
- DRUG use
- OVER stimulation
- ELECTROLYTE abnormalities
- REDUCED sensory input
- CIRCULATORY, RENAL, PULMONARY disorders
- Severe, uncontrolled PAIN
- NUTRITIONAL deficiencies
- Establish ____ of delirium
- Establish an underlying ____
- Thorough history of ____ and ____ of mental status changes (if on and off then prob not delirium, be pt. advocate)
- ____ exam my be challenging
- Establish PRESENCE of delirium
- Establish an underlying CAUSE
- Thorough history of FREQUENCY and DURATION of mental status changes
- PHYSICAL exam may be challenging
- Underlying ____ (medication, over-stimulation)
- ____ contributing factors
- ____ control
- Maintenance of ____
- Underlying FACTORS
- REMOVE contributing factors
- BEHAVIORAL control
- Maintenance of SAFETY
- ____ environment
- Divert attention from ____ things
- Playing soothing ____
- ____ activities (take focus off - crossword, cold wash cloth)
- ____ cause (environment, stimuli)
- SAFE environment
- Divert attention from UNFAMILIAR things
- Playing soothing MUSIC
- DIVERSIONAL activities
- REMOVE cause
With dementia, you can have ____ too.
- ____ (> 6 mo)
- ____ (gradual deterioration)
- Slow, ____ (developing gradually)
- Duration months to many ____
- ____ (mental action) decline, ____ (can't go back)
- Different ____ of dementia
- Meds to ____ process but not ____
- Most common is Dementia of ____ type (50%)
- Slow, PROGRESSIVE
- Duration months to many YEARS
- COGNITIVE decline, IRREVERSIBLE
- Different TYPES of dementia
- Meds to SLOW process but not TREAT
- Most common is Dementia of ALZHEIMER'S type
True or False: Alzheimer's disease only affects "old people"
False - early onset is usually 40 y/o
True or False: Alzheimer's disease is a memory problem. It doesn't kill.
False - can kill - develop physical problems that can cause pneumonia, ulcer, etc.
True or False: Alzheimer's disease can't be accurately diagnosed.
False - Assessment can be done to rule things out
True or False: Alzheimer's disease affects a relatively small number.
False - Increasing with aging population
True or False: Alzheimer's disease is un-treatable.
False - Meds to help control
True or False: Alzheimer's disease cannot be prevented.
False - being healthy, using your brain, learning new things
True or False: Alzheimer's disease is not a serious financial issue.
Areas of the brain affected by Alzheimer's disease
- C___ C___ (outer layer of brain - surface)
- B___ F___ (major area for colinergic output - produces Acetylcholine)
- H____ (primary area for forming memories, esp. new ones)
- Cerebral Cortex
- Basal Forebrain
- Dementia seen in 60% of people > ____ y/o
- ____ most expensive disease in U.S.
- 1 million w/ Alzheimer's disease cared for in ____
- Disease from onset to death is __ - __ years
With dementia, axons in the brain ____.
Dementia Risk Factors:
- ____ (not one single reason why got Alzheimer's disease)
- ____ (older at increased risk, greater after age 80)
- ____ link (familial, APOE gene - risk is 50% greater if both parents have vs. one)
- ____ link (down syndrome)
- ____ factors (too much exposure to metal, viral links)
- Hereditary Link
- Chromosome Link
- Environmental Factors
Changing Brain and Alzheimer's disease
- Brain weight ____ more
- Marked ____ atrophy (wasting away)
- ____ more significantly: cerebral fissures, sulci, & ventricles
- Other significant areas affected: H____ and works outwards, loss of ____
- Brain weight DECREASES more
- Marked CEREBRAL atrophy
- ENLARGED more significantly - cerebral fissures, sulci, & ventricles
- Other significant areas affected - HIPPOCAMPUS and works outwards, loss of CONNECTIONS
With dementia, microscopic changes in the brain can only be seen with ____.
Formation of Plaques: Plaques are dense deposits of ____ and cellular material outisde and around the ____.
Formation of Plaques: Formed from Beta ____ ____ ____ (APP)
Amyloid Precursor Protein (APP) - Increase in APP, Decrease in Acetylcholine (up to 70%)
Formation of Plaques: ____ ____ - APP molecule snipped at different locations, fragments are longer, stickier, unable to dissolve.
Formation of Plaques: ____ clump together forming plaques.
Formation of Tangles: ____ _____ have internal support structure which includes microtubules.
Formation of Tangles: ____ (protein) helps stabilize microtubules.
Formation of Tangles: ____ ____ - Chemical makeup of Tau changes causing it to unravel and destabilize the microtubules.
Formation of Tangles: Disintegrating pieces of ____ clump together in the cell to form ____.
Types of Dementia:
- A_____ type (most common)
- V____ D____ (ischemic insult to brain - small ischemic infarcs in brain; rapid)
- F____ D____ (neuron atrophies instead of plaques & tanges; unique behavior changes, affects more-so frontal lobe)
- Alzheimer's Type
- Vascular Dementia
- Frontotemporal Dementia
- Progressive decline in __ or ____ areas (memory, language, calculation, Judgment, abstraction, behavior, visual-spacial perception)
- Onset b/w __-__ years of age
- Noted ____ deterioration
- Other causes ____ ____ (Dx by exclusion)
- Progressive decline in 2 or MORE areas
- Onset b/w 40-90 years of age
- Noted PROGRESSIVE deterioration
- Other causes RULED OUT
Supporting Dx Tests:
- L___ T___ (drug toxicity, Dehydration, Alcohol Study)
- _ _ or _ _ _ (rule out bleed, can show cerebral atrophy, can show tumor, show enlargement of ventricles, show latter tages of enlargement of sulci or gyri)
- _ _ _ (shows how cells use glucose - decrease in metabolic activiy, metabolism of glucose)
- _ _ _ (increase delta wave activity seen in 2nd or 3rd stage of Alzheimer's)
- Laboratory Tests
- CT (computed tomography) or MRI (Magnetic Resonance Imaging)
- PET (Position Emission Tomography)
- EEG (Electroencephalogram)
Dementia - Changes in cognition is ____.
Characteristics of Dementia of Alzheimer's Type:
- Loss / Decrease of ____
- Change in ____ skills
- Decreased ____ / ____ solving
- Changes in ____ perception
- Change in P____
- ____ impairment over time.
- ____ deterioration through the disease
- Increase in ____ (flat effever, overall)
- End result is ____
- Loss / Decrease of MEMORY
- Change in LANGUAGE skills
- Decreased JUDGMENT / PROBLEM solving
- Changes in VISUOSPATIAL perception
- Change in PERSONALITY
- COGNITIVE impairment over time
- PHYSICAL deterioration through the disease
- Increase in STUPOR
- End result is DEATH
Staging the Characteristics of Alzheimer's:
- ____ broad
- M___, M___, S___ (stage 1, 2, 3 respectively)
- Stages __-__
- ____ not always orderly (overlap of stages, 1-2, 2-3)
- Mild, Moderate, Severe
- Stages 1-3
Assessment Tools: N___ F___ S___
- ____ Sheet
- ____ - Appropriate / Inappropriate
- _ _ _ - Alert, confused, forgetful, unresponsive
- ____ - Clear, slurred, aphasic
- ____ - Person, place, time
- ____ Scale
- Assessment Tools - NURSING FLOW SHEET
- NEURO sheet
- BEHAVIOR - Appropriate / Inappropriate
- LOC - Alert, confused, forgetful, unresponsive
- SPEECH - Clear, slurred, aphasic
- ORIENTATION - Person, place, time
- RANCH scale
Tool used for neuro and to stage orientation (Levels I - VIII)
Mini-mental status exam used to assess ____ impairment.
Mini-mental status exam assesses areas of
- R____ (give 3 words & have them repeat back 5 min later)
- S____ & L____
- Speech & Language
Ability of the brain to process, store, retrieve, and manipulate information.
Changes in Behavior & Personality (Usually Stage __)
- A____ (Physical or verbal)
- Rapid ____ swings
- Increased ____ at night (sun downing)
- W____ (safety)
- Changes in Behavior & Personality (Usually Stage II)
- AGGRESSIVENESS (physical or verbal)
- Rapid MOOD Swings
- Increased CONFUSION at night (sun downing)
- WANDERING (safety)
Change in Self-Care:
- B____ & B____ issues
- Inappropriate ____ selections
- ____ to eat
- D____ look (don't have an interest in how they look)
- BOWEL & BLADDER issues
- Inappropriate CLOTHING selections
- FORGET to eat
- DISHEVELED look
Primary Nursing Dx:
- S____-C____ Deficit
- T____ P____, Disturbed
- S____ P____, Disturbed (visual, auditory, kinesthetic)
- C____, Ineffective
- C____ Role Strain
- F____ P____, Interrupted
- SELF-CARE Deficit
- THOUGHT PROCESS, Disturbed
- SENSORY PERCEPTION, Disturbed
- COPING, Ineffective
- CAREGIVER Role Strain
- FAMILY PROCESSES, Interrupted
- C____ I____
- A____p____ Drugs
- C____ / A____
- Cholinesterase Inhibitors
- Antipsychotic Drugs
- Complementary / Alternative
Promotion & Prevention
- No ____ prevention methods
- Research on ____
- M____ (Decreased use of NSAIDs)
- No PROVEN prevention methods
- Research on DIET
Stages of Alzheimer's Disease: Truly forgetful, they recognize but nobody else does. Stage?
Stage I (Early, Mild)
Stages of Alzheimer's Disease: Wild stage, up and moving and doing things; confused; overwhelmed. Stage?
Stage II (Middle, Moderate)
Stages of Alzheimer's Disease: MMore dependent, incapacitated, confused and need help; severe physical decline; don't remember family. Stage?
Stage III (Late, Severe)
Nursing Interventions of Alzheimer's Disease: Stage I
- R____ (person, place, time)
- ____ Stimuli
- Bed ____
- ____ self-care
- Keep ____ things with them
- P____ of A____
- DECREASE stimuli
- Bed CHECK
- PROMOTE self-care
- Keep FAMILIAR things with them
- POWER of ATTORNEY
Nursing Interventions of Alzheimer's Disease: Stage II
- ____ stimuli
Nursing Interventions of Alzheimer's Disease: Stage III
- ____ Care
- R____ of M____
- ____ Checks
- T____ any affected areas (respiratory, skin)
- TOTAL care
- RANGE of MOTION
- SKIN checks
- TREAT any affected areas
Primary Goals of Alzheimer's Disease: Stage I
- C____ (decisions for self)
- E____ (them, family)
Primary Goals of Alzheimer's Disease: Stage II
- S____ (#1)
- M____ (physically)
- Helps with a lot of A____ of D____ L____
- Avoid C____
- B____ & B____ training
- _____ remenising
- Keep ____ items w/ them
- MAINTENANCE (physically)
- Helps w/ a lot of ACTIVITIES of DAILY LIVING
- Avoid CONFRONTATION
- BOWEL & BLADDER training
- ENCOURAGE remenising
- Keep FAMILIAR items with them
Primary Goals of Alzheimer's Disease: Stage III
- S____ care
- ____ incidence of physical complications
- SUPPORTIVE care
- DECREASE incidence of physical complications
Most common drug used to medicate those with mild to severe Alzheimer's disease.
This drug is given for moderate to severe Alzheimer's disease.
Drugs A____ & N_____ work best together at end stage of Alzheimer's disease.
Vitamin __ is no longer recommended in patients at ris kfor developing Alzheimer's disease because of the evidence that its supplementation increases the risk for all = cause mortality.
If Alzheimer's disease is conrfirmed and the petient has no significant risk of heart disease then Vitamin __ 1000 IU can be given twice daily.
In stage I Alzheimer's disease, plaques and tangles begin to form in areas associated with
L____ and M____
T____ and P____
- LEARNING and MEMORY
- THINKING and PLANNING
In mild to moderate (stage II) Alzheimer's disease, more plaqes and tangles form in areas for memory, learning, thinking and planning but also spreads to areas involved in
- S___ and understanding S___
- S___ of where your body is in relation to ____ around you
- SPEAKING and understanding SPEECH
- SENSE of where your body is in relation to OBJECTS around you
As Alzheimer's progresses, individuals may experience changes in p____ and b____ and have trouble recognizing friend and family members.
In severe (stage III) Alzheimer's disease, most of the c___ is seriously damaged. The brain s____ dramatically due to widespread cell death.
In severe (stage III) Alzheimer's disease, individuals lose their ability to c____, r____ family and loved ones, and c___ for themselves.
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