DEMENTIA , DELIRIUM & ALZHEIMER’S DISEASE

 DEMENTIA, DELIRIUM & ALZHEIMER’S DISEASE

DEMENTIA

Definition

Dementia,  is a syndrome characterized by progressive, usually irreversible, global cognitive (mental activity) deficits such as memory, language, emotion, personality which is of sufficient severity to interfere with one’s normal & occupational functioning.

Clinical Features

·       Memory impairment (starts with short-term and progresses to long-term) which is impaired ability to learn new information or to recall previously learned information

·       Impairment in abstract thinking, judgment, & impulse control.

·       Aphasia – difficulties in naming objects, or in speaking.

·        Dysphasia(DIFFICULT IN TALKING)

·        Agnosia-DIFFICULT IN RECOGNISING FAMILIAR PEOPLE

·       Apraxia – loss of ability to carry out purposeful, complex movement and to use objects properly.

·       Impaired executive functioning

·       Personality disintegration: History of personality change, forgetfulness, social withdrawal, lability of affect, disinhibition, diminished self care, apathy, fatigue, deteriorating executive functioning.

·       Significant impairment of normal functioning

·       Hallucinations and delusions often paranoid

·       Anxiety or/and depression in some

·       Neurological features (eg. Seizures, focal deficits)

·       Disorientation

·       Wandering

Differential Diagnosis

·       Delirium

·       Depression

Common Causes

·       Alzheimer’s disease (55%)

·       Vascular dementia (20%)

·       General medical condition eg. HIV/AIDS

·       Substance induced.

DELIRIUM

Definitions

·       Delirium is a state of mental confusion & excitement characterized by disorientation for time and place usually with illusions and hallucinations.

·       It can also be described as disturbance of consciousness & a change in cognition that develops rapidly over a short period of time.

ETIOLOGY

1.     Delirium due to a general medical condition – systemic infections (e.g. HIV/AIDS opportunistic), metabolic disorders, fluid and electrolyte imbalance, liver or kidney disease, encephalopathy (e.g. HIV/AIDS) and head trauma.

2.     Substance induced delirium – anticonvulsants, neuroleptics, anxiolytics, antidepressants, cardiovascular medications, antineoplastic and hormones.

3.     Substance intoxication – Delirium symptoms occurring in response to taking high doses of cannabis, cocaine, hallucinogens, alcohol, anxiolytics or narcotics.

4.     Substance withdrawal delirium- Reduction or termination of long term, high dose use of certain substance like alcohol, sedatives, hypnotics, or anxyliotics.

5.     Delirium due to multiple etiologies – Symptoms may be related to more than one general medical condition to combined effects of general medical condition & substance use.

 

SYMPTOMS OF DELIRIUM

·       Altered consciousness ranging from hyper vigilance to stupor or semi coma

·       Extreme distractibility with difficulty focusing attention

·       Disorientation to time & place

·       Impaired reasoning ability & goal directed behavior

·       Disturbance of sleep

·       Emotional instability manifested by fear, anxiety, depression, irritability, anger.

·       Misperception of the environment – hallucinations, illusions

·       Autonomic manifestations such as tachycardia, sweating, flushed face, dilated pupils, elevated BP

·       Incoherent speech

·       Impairment of recent memory

 DIFFERENCES BETWEEN DELIRIUM AND DEMENTIA

CHARACTERISTIC	DELIRIUM	DEMENTIA
Onset	Acute	Gradual, insidious
Course	Transient, fluctuating	Stable
Duration	Hours to days	Months to years
Attention	Impaired	Preserved
Consciousness	Impaired	Preserved
Mood	Fear, perplexity	Apathy, low mood
Delusions Perceptual changes	More likely	Less likely

 

NURSING DIAGNOSIS FOR DEMENTIA AND DELIRIUM

·       Risk for trauma related to disorientation, confusion, weakness, seizures, memory impairment, poor vision, extreme psychomotor agitation etc

·       Risk for violence, self & others directed related to delusional thinking, suspiciousness, hallucinations, illusions, disorientation, confusion etc

·       Altered thought process (delusions) related to alterations in structure/function of brain tissue secondary to advanced age, vascular disease, hypertension etc

·       Self care deficit, (ADLs) related to disorientation, confusion, memory deficit.

·       Sensory perceptual alterations (hallucinations) related to alterations in structure/function of brain tissue secondary to advanced age, cerebral hypoxia, hypertension etc

·       Self esteem disturbance related to loss of independent functioning, loss of capacity to remember, loss of capability for effective verbal communication.

·       Care giver role strain related to severity and duration of care receiver’s illness, inadequate physical environment for providing care, family or care giver isolation, complexity and amount of care giving tasks.

 

NURSING INTERVENTIONS FOR DELIRIUM, DEMENTIA

·       Conduct risk (to self- suicidal etc/ to others) assessment so as to institute safety measures which include:

1.     Arrange furniture in a way that best accommodates pt’s disability

2.     Observe pt closely (One to one nursing, e.g. Accompany/assist pt. ambulate

3.     Place items that pt uses frequently within easy access.

4.     Remove potentially harmful items from client’s room.

5.     Pad side rails and head board of pt with frequent seizures & institute seizure precautions.

·       Orient to reality (time, place, and person) frequently.

·       Teach caregiver successful methods of preventing harm to pt and orientation of pt.

·       Maintain low levels of stimulation e.g. Sounds, light, too many visitors etc as these lead to increased anxiety.

·       Sufficient staff to restrain pt when necessary

·        Maintain calm manner with pt

·       Interrupt periods of unreality & reorient

·       Teach relaxation exercises to be used when anxious

·       Provide simple & structured environment to minimize confusion:

1.     Identify self care deficit & provide assistance as required

2.     Allow plenty of time for pt to perform task

3.     Provide guidance/support for independent functioning

4.     Provide structured scheduled activities that do not change from day to day

5.     ADLs should follow home routine

6.     Nurse in familiar environment such as patient’s own home.

 

ALZHEIMER’S DISEASE

It is the most common cause of dementia in older people.

Definition

It is a degenerative disease of the brain with prominent cognitive and behavioral impairment that is sufficiently severe to interfere significantly with social and occupational function.

Risk factors

·       Increases with age after 60

·       Ratio is 1:4 female vs. male

·       Down’s syndrome

·       Previous head injury

·       Parkinson’s disease

Protective factors

·       Smoking

·       Oestrogen

·       Vit E

·       Higher level of pre-morbid education

Clinical features

Symptoms usually start insidiously but first presentation may be related to an identifiable life event.

·       Early symptoms: forgetfulness, deterioration in self care, wandering, irritability & cognitive defects.

·       Disorientation

·       Aphasia

·       Psychiatric symptoms: Delusions – usually paranoid. Auditory and/ or visual hallucinations, depression.

·       Behavioral disturbances: aggression, wandering, explosive temper, sexual disinhibition, incontinence, excessive eating, and searching behavior.

·       Personality change: exaggeration of premorbid traits.