Nursing Care Management for Dementia

Dementia is the slow opposite of delirium: insidious onset, chronic, progressive, and irreversible. It is not one disease but an umbrella for conditions that grind down memory, thinking, reasoning, and daily function beyond normal aging. As the population ages, you will see more of it, and the weight falls on families and caregivers as much as on the patient.

What is Dementia?

Dementia describes a group of progressive neurological disorders that decline cognitive function and memory, affecting thinking, behavior, and the ability to perform daily activities. It often stems from underlying medical conditions, substance use, or medication effects. Onset is slow and insidious; the course is chronic, progressive, and irreversible.

Statistics and Incidences

Cases are rising as life expectancy climbs. Four clinical dementia syndromes account for 90% of all cases once other reversible causes of cognitive impairment are excluded. Dementia and Alzheimer's disease are expected to double every 20 years, from 47 million people in 2015 to 75 million in 2030 and 131 million in 2050.

Causes

• Dementia of the Alzheimer's type. Cause unknown; proposed mechanisms include reduced brain acetylcholine, plaque and tangle formation, serious head trauma, and genetic factors. Brain changes include atrophy, enlarged ventricles, and numerous neurofibrillary plaques and tangles.
• Vascular dementia. Significant cerebrovascular disease. The client suffers the equivalent of small strokes from arterial hypertension or cerebral emboli or thrombi, destroying many brain areas. Onset is more abrupt than in AD and progresses in steps rather than gradual decline.
• Dementia due to HIV disease. Immune dysfunction from HIV opens the brain to other infections, and HIV itself appears to cause dementia directly.
• Dementia due to head trauma. Brought on by traumatic head injury.
• Dementia due to Lewy body disease. Clinically similar to AD but tends to progress faster, with earlier visual hallucinations and Parkinsonian features. Distinguished by Lewy bodies, eosinophilic inclusion bodies seen in the cerebral cortex and brainstem.
• Dementia due to Parkinson's disease. Loss of nerve cells in the substantia nigra of the basal ganglia; symptoms closely resemble AD.
• Dementia due to Huntington's disease. Transmitted as a Mendelian dominant gene, with damage in the basal ganglia and cerebral cortex.
• Dementia due to Pick's disease. Atrophy in the frontal and temporal lobes; often misdiagnosed as AD.
• Dementia due to Creutzfeldt-Jakob disease. Caused by a transmissible "slow virus" or prion. The course is extremely rapid, with progressive deterioration and death within one year of onset.
• Dementia due to other general medical conditions. Endocrine conditions, pulmonary disease, hepatic or renal failure, cardiopulmonary insufficiency, fluid and electrolyte imbalances, nutritional deficiencies, frontal or temporal lobe lesions, uncontrolled epilepsy, CNS or systemic infections, and other neurological conditions.
• Substance-induced persisting dementia. Persisting effects of alcohol, inhalants, sedatives, hypnotics, anxiolytics, other medications, and environmental toxins.

Clinical Manifestations

• Memory impairment: trouble learning new information or recalling what was learned.
• Impaired abstract thinking, judgment, and impulse control.
• Impaired language ability, such as difficulty naming objects; some patients stop speaking entirely (aphasia).
• Personality changes.
• Impaired ability to perform motor activities despite intact motor function (apraxia).
• Disorientation to place, time, or the names of people close to them.
• Wandering, driven by disorientation.
• Delusions, particularly of persecution.

Assessment and Diagnostic Findings

Labs rule out other causes of cognitive impairment.

• Complete blood cell count (CBC). Abnormal CBC and cobalamin levels prompt workup for hematologic disease.
• Liver enzyme levels. Abnormalities prompt workup for hepatic disease.
• Thyroid-stimulating hormone (TSH). Abnormalities prompt workup for thyroid disease.
• Rapid plasma reagent (RPR). Abnormalities prompt workup for syphilis.
• HIV serology. Abnormal serology or PCR prompts workup for HIV/AIDS.
• Paraneoplastic antibodies. Abnormalities prompt workup for autoimmune encephalitis.
• CSF proteins. Abnormal tau, P-tau, and 14-3-3 prompt workup for Creutzfeldt-Jakob disease.

Medical Management

Only symptomatic therapies exist; none alter the course of the disease.

• Experimental therapies. Anti-amyloid therapy, reversal of excess tau phosphorylation, estrogen therapy, vitamin E therapy, and free radical scavengers have all yielded disappointing results.
• Dietary measures. No special diet exists, though caprylidene (Axona), a prescription medical food, is metabolized into ketone bodies the brain can use for energy when glucose processing fails. Brain imaging of older adults and patients with dementia shows dramatically decreased glucose uptake.
• Physical activity. Routine activity and exercise may slow progression and protect brain health. Keep the patient's surroundings safe and familiar, and hold structured routines around meals, medication, and cognitive activities to lower stress.

Pharmacological Management

The mainstay is centrally acting cholinesterase inhibitors, used to offset acetylcholine depletion in the cerebral cortex and hippocampus.

• Cholinesterase inhibitors. Palliate the cholinergic deficiency.
• N-methyl-D-aspartate antagonists. Memantine is the only FDA-approved NMDA antagonist; used alone or with AChE inhibitors.
• Nutritional supplement. Medical foods address specific nutritional problems caused by disease; caprylidene is indicated for dietary management of metabolic processes in mild to moderate dementia.

Nursing Management

Nursing Assessment

• Psychiatric interview. Describe mental status: behavior, flow of thought and speech, affect, thought processes and content, sensorium and intellectual resources, cognitive status, insight, and judgment.
• Serial assessment. Repeated assessment tracks the fluctuating course and acute changes; include family interviews, which are crucial for young children with cognitive disorders.

Nursing Diagnosis

• Risk for trauma related to disorientation or confusion.
• Risk for self-directed or other-directed violence related to delusional thinking.
• Chronic confusion related to altered brain tissue structure or function.
• Self-care deficit related to cognitive impairment.
• Risk for falls related to cognitive impairment.

Nursing Care Planning and Goals

The client will accept explanations of inaccurate interpretations of the environment and, with caregiver help, interrupt non-reality-based thinking.

Nursing Interventions

• Orient frequently. Keep familiar objects, a clock, a calendar, and daily schedules within reach to maintain reality orientation.
• Teach caregivers to reorient. They will be responsible for client safety after discharge.
• Give positive feedback. Reinforce appropriate thinking and behavior, and reward the client for recognizing that an idea is not reality based; this builds self-esteem.
• Keep communication simple. Use simple explanations and face-to-face interaction. Do not shout into the ear; speaking slowly and face to face works best with an elderly patient with hearing loss.
• Discourage suspiciousness. Express reasonable doubt when the client voices suspicious beliefs, and discuss the personal cost of continued suspiciousness.
• Do not feed false ideas. Refuse to let false ideas take hold; redirect to real people and real events.
• Observe closely. Watch closely when delusional thinking signals intent to harm; client safety is the priority.

Evaluation

Goals are met when the client, with caregiver help, distinguishes reality-based from non-reality-based thinking, and caregivers can describe ways to reorient the client as needed.

Documentation Guidelines

Document individual findings (contributing factors, interactions, social exchanges, specific behaviors); cultural and religious beliefs and expectations; the plan of care; the teaching plan; responses to interventions and teaching; and progress toward outcomes.