Delirium

 Etiology and physiology

o Delirium is a state of temporary, but acute mental confusion
o It is the most frequent complication of hospitalization in older adults
 15-53% of older adults experience delirium postoperatively

 80% of older adults in an ICU experience delirium

o Older patients have limited compensatory mechanisms to deal with physiologic insults such
as
 Hypoxia
 Hypoglycemia
 Dehydration
o Older adults are also most susceptible to drug-induced delirium because of their increased
used of multiple drugs
o Delirium is rarely caused by a single factor – it is often the result of an interaction between
the patient’s underlying condition and a precipitating event (eg. minor changes, major
surgeries, infection, sleep deprivation, anesthesia)

o Factors that can precipitate delirium:

 Cognitive status
 Dementia
 Cognitive impairment
 History of delirium
 Depression
 Functional status
 Function dependence
 Immobility
 History of falls
 Sensory
 Sensory deprivation
 Sensory overload
  Decreased oral intake
 Dehydration
 Malnutrition
 Environmental
 Admission to ICU
 Use of physical restraints
 Pain (untreated)
 Emotional stress
 Prolonged sleep deprivation
 Drugs
 Sedative-hypnotics
 Opioids
 Anticholinergic drugs
 Treatment with multiple drugs
 Alcohol or drug abuse/withdrawal
 Coexisting medical conditions
 Severe acute or terminal illness
 Chronic renal or hepatic disease
 History of stroke
 Neurologic disease
 Infection/sepsis
 Fracture or trauma
 Surgery
 Orthopedic surgery
 Cardiac surgery
 Prolonged cardiopulmonary bypass
 Noncardiac surgery
 Delirium manifestations
o Early
 Inability to concentrate
 Irritability
 Insomnia
 Loss of appetite
 Restlessness
 Confusion
o Late
 Agitation
 Misperception
 Misinterpretation
 Hallucinations
o *A key distinction between delirium and dementia is that the person who exhibits
sudden cognitive impairment, disorientation, or clouded sensorium is more likely to
have delirium
 Laboratory Values
o Serum electrolytes
o Liver and thyroid function tests
o Blood urea nitrogen level
o Creatinine level and urinalysis
o Complete blood count (CBC)
o Drug and alcohol levels
 Toxicology screen
 Diagnostics
o Medical and psychological history
o Physical examination and medication record
 What medications is the patient currently taking?
o Electrocardiogram (ECG)
o Oxygen saturation level
o Lumbar puncture
 Drug therapy – reserved for patients with severe agitation; drugs should be used only when
nonpharmacologic interventions have failed
o Dexmedetomidine (Precedex) – alpha-adrenergic receptor agonist
 For sedation
o Neuroleptics – antipsychotics
 Haloperidol (Haldol)
 Risperidone (Risperdal)
 Olanzapine (Zyprexa)
 Quetiapine (Seroquel)
 Monitor the patient for side effects – hypotension, extrapyramidal side effects,
muscle tone changes, and anticholinergic effects
o Short-acting benzodiazepines – lorazepam (Ativan)
 Nursing interventions
o Identify patients who are at high-risk
 Patient with neurologic disorders (eg. stroke, dementia, CNS infection,
Parkinson’s disease)
 Sensory impairment
 Advanced age
 Patients in ICU
 Patients with untreated pain
o Eliminate precipitating factors
 Correct electrolyte imbalances and nutritional deficiencies
 Make changes to the environment if overstimulating or understimulating to the
patient
 Reduce lights and noises
 Treat infections with antibiotic therapy
o Protect the patient from harm
 Create a safe and calm environment
 Ask family to bring familiar objects to decorate the room
  Encourage family members to stay at bedside
 Move patient to a private room or one closer to the nurse’s station
 Plan for consistent nursing staff
 Avoid the use of restraints
o Reorientation and behavioral interventions
 Provide the patient with reassurance and reorienting information as to place,
time, and procedures
 Clocks, calendars, and lists of the patient’s scheduled activities are useful in
reducing confusion

Dementia Delirium
Onset Usually insidious Rapid, often at night
Progression Slow Abrupt
Duration Years (8-20 years) Hours to days to weeks
Thinking Difficulty with abstract thinking, Disorganized, distorted. Slow or
impaired judgement, words accelerated incoherent speech
difficult to find
Perception Misperceptions often present; Distorted; delusions and
delusions and hallucinations hallucinations
Psychomotor behavior May pace or be hyperactive; as Variable; can be hyperactive or
disease progresses, may not be hypoactive, or mixed
able to perform tasks or
movements when asked
Sleep-wake cycle Sleeps during day with frequent Disturbed sleep – reversed
awakenings at night – sleep-wake cycle
fragmented sleep

Dementia

 Etiology and pathophysiology

o Dementia is a syndrome characterized by loss of memory, orientation, attention, language
skills, judgement, and reasoning
 Personality changes and behavioral problems such as agitation, delusions, and
hallucinations may occur
o Unable to reverse neuronal degeneration, but treatments may improve quality of life
o The most common causes of dementia are:
 Neurodegenerative conditions
 Alzheimer’s disease
 Down syndrome
 Amyotrophic lateral sclerosis
 Parkinson’s disease
 Huntington’s disease
 Vascular disorders
 Vascular dementia is a loss of cognitive function due to ischemic or
hemorrhagic brain lesions caused by cardiovascular disease
 o When the arteries that supply the brain become narrowed or
blocked off, blood supply is decreased
o Vascular dementia may be also caused by a single stroke or multiple
strokes
 Subarachnoid hemorrhage
 Chronic subdural hematoma
 Dementia with Lewy Bodies
 Characterized by presence of Lewy bodies in brainstem and cortex
 Typically have symptoms of parkinsonism
 Creutzfeldt-Jakob disease
 Rare and fatal brain disorder
 Caused by a prion protein
o Found in beef from animals infected with mad cow disease
o Transmission of blood
o Risk factors
 Aging
 Family history of dementia
 Those with a first-degree relative with dementia are more likely to develop
the disease
 Diabetes mellitus
 Diabetes increases a person’s risk of developing AD or other types of
dementia because insulin resistance may interfere with the body’s ability to
break down amyloid, a protein that forms brain plaques - these plaques are
commonly found in patients with AD
 High blood glucose also causes oxidative stress and plays a role in
atherosclerosis, which contributes to vascular dementia
 Obesity
 Smoking
 Personal health history of atrial fibrillation
 Hypertension
 Hypercholesterolemia
 Coronary artery disease
 Head trauma
 Signs and symptoms
o Depending on the cause of the dementia, the onset of manifestations may be insidious or
abrupt
 Dementia with neurologic degeneration progresses over time
 Vascular dementia results in symptoms that appear suddenly or progress in a step-
wise pattern
o Dementia and depression often occur together in patients:
 Sadness
 Difficulty thinking and concentrating
 Fatigue
 Apathy
  Feelings of despair
 Inactivity
 When depression is severe, memory and functional impairment may result
o Other signs and symptoms of dementia are similar to Alzheimer’s disease
 Diagnostic studies
o Perform a thorough medical, neurologic, and psychologic history
o CT and MRI
 Diagnoses vascular causes of dementia by detecting the presence of brain lesions
 Nursing management
o Similar to the management of a patient with Alzheimer’s disease
o Prevent vascular dementia by controlling the patient’s hypertension, diabetes, and
hypercholesterolemia and by teaching the patient not to smoke

Alzheimer’s disease

 Etiology and pathophysiology

o Alzheimer’s disease is a chronic, progressive, degenerative disease of the brain and is the
most common form of dementia
o AD is the sixth leading cause of death in the United States
o AD manifests 2 to 20 years after the onset of symptoms of dementia
o Average duration of disease process is 8 years – de
o ath typically occurs 4 to 8 years after diagnosis
o The incidence of AD is slightly higher in African Americans and Hispanic Americans than in
whites, and is associated with lower socioeconomic status and educational level, and poor
access to health care
o Women are more likely than men to develop AD
o Characteristic findings of AD relate to changes in the brain’s structure and function, and
includes the presence of:
 Amyloid plaques
 Amyloid plaques consist of clusters of a protein called beta-amyloid, which
is cleaved from amyloid precursor protein (APP)
 In AD, plaques first develop in areas of the brain used for memory and
cognitive function, including the hippocampus
 Eventually, the plaques deposit in areas of the cerebral cortex that are
responsible for language and reasoning
 Neurofibrillary tangles – abnormal collections of twisted protein threads inside
nerve cells
 Tau proteins
 Loss of connections between neurons
 Acetylcholine is a neurotransmitter that is essential for processing memory
and learning; decreased in both concentration and function in patients
with Alzheimer's disease.
 Neuron death
 Affected parts of the brain undergo atrophy, causing the size of the brain to
shrink
 o The etiology of AD maybe a combination of genetic and environmental factors
 Age is the most important risk factor for developing AD
 Familial Alzheimer’s disease occurs in individuals with a clear pattern of AD
inheritance in their family
 FAD is associated with an early onset (before 60 years of age) and a more
rapid disease course
 Genetic mutations may affect how the brain processes beta-amyloid proteins,
causing overproduction of the protein in the brain tissue
 Familial
o Persenilin-1 (PS1) Presenilin-2 (PS2) and amyloid precursor protein
(APP) genes play significant role in how the brain processes β-
amyloid protein
o Mutations of these genes results in a buildup of Beta-amyloid
 ↑ β-amyloid protein  ↑ risk
 Sporatic
o APOE (subtype epsilon 4) are important in protein transport for
cholesterol and other fats in the body
 ApoE-2
 ApoE-3
 ApoE-4
o Mutations of these alleles prevent breakdown of protein buildup
 Diabetes mellitus
 Hypertension
 Hypercholesterolemia
 Coronary artery disease
 Obesity
 Cardiac dysrhythmias
 Current smoking
 Head trauma
 Signs and symptoms
o Early warning signs of Alzheimer’s disease:
 Memory loss that affects job skills
 Difficulty performing familiar tasks
 Problems with language
 Disorientation to time and place
 People with AD can become lost on their own street, not knowing where
they are, how they got there, or how to get back home
 Poor or decreased judgement
 Problems with abstract thinking
 Misplacing things
 Changes in mood and behavior
 Rapid mood changes for no apparent reasons
 Changes in personality (suddenly or overtime)
 Loss of initiative
 o The initial manifestations are related to changes in cognitive functioning – memory loss,
mild disorientation, or trouble with words and numbers
 With time and progression of AD, changes in cognitive functioning can affect the
ability to perform self-care and personal hygiene deteriorates
o Ongoing loss of neurons can cause a person to act impulsive and unpredictable, and they
may experience rapid mood swings involving agitation and aggression
 Some patients also develop delusions and hallucinations
o Addition cognitive impairments include:
 Dysphagia – difficulty understanding language and oral communication
 Apraxia – inability to manipulate objects or perform purposeful acts
 Visual agnosia – inability to recognize objects by sight
 Dysgraphia – difficulty communicating via writing
o Later in the disease long term memories cannot be recalled and the patient can lose the
ability to recognize family members and friends, communicate, and perform activities of
daily living – the patient becomes unresponsive and requires total care
o Retrogenesis -a theory that suggests there is a relationship between the developmental
stages in children and the deterioration in AD patient
 Diagnostic criteria for Alzheimer’s disease
o Preclinical Alzheimer’s disease
 Brain changes, including amyloid buildup and other early neuron changes, may
already be in the process
 Amyloid buildup can be detected with PET scans and CSF analysis
 No significant clinical symptoms are evident
o Mild Cognitive Impairment (MCI) due to Alzheimer’s disease
 Marked by symptoms of memory problems, but not compromising a person’s
independence
 May or may not progress to Alzheimer’s dementia
 Continue ongoing monitoring of the patient for changes in memory and thinking
skills that would indicate a worsening of symptoms or progression to dementia
o Dementia due to Alzheimer’s disease
 Characterized by memory, thinking, and behavioral symptoms that impair a person’s
ability to function in daily life
 Dementia marks the terminal stage of AD
 Diagnostic studies
o *A definitive diagnosis of AD usually requires examination of the brain tissue at autopsy to
find the presence of neurofibrillary tangles and plaques
o Complete health history
o Physical examination
o Neuropsychologic testing – help document degree of cognitive impairment and to
determine a baseline from which to evaluate change over time
 Mini-Cog – a brief assessment tool for cognitive impairment
 Mini-Mental State Examination may not be helpful in early stages of AD
 Montreal Cognitive Assessment (MOCA) is more sensitive during the early stages of
AD
 o Brain imaging tests – identifies cognitive loss and presence of vascular brain lesions
 CT
 MRI
 MRS
 PET
o Use of biomarkers to represent the level of beta-amyloid accumulation in the brain and the
extent of nerve cell injury or degeneration:
 CSF neurochemical markers – beta-amyloid and tau proteins
 Imaging biomarkers – volumetric MRI and PET
 Volume of the brain correlates with neurodegeneration
 PET can also be used to detect amyloid plaques
 Collaborative care
o There is no cure for Alzheimer’s disease and no treatment is available to stop the
deterioration of the brain cells
o The collaborative management of AD is aimed at:
 Controlling the undesirable behavioral manifestations that the patient may exhibit
 Providing support for the family and caregiver
o Drug therapy
 Medication that helps with decreased memory and cognition:
 Cholinesterase inhibitors
o Action – prevents the breakdown of acetylcholine in the synaptic
cleft
 N-methyl-D-aspartate (NMDA) receptor antagonists
o Action – protects the brain’s cells by blocking the action of
glutamate
 Depression
 Selective serotonin reuptake inhibitors (SSRIs)
 Behavioral problems (eg. agitation, physical aggression, disinhibition)
 Antipsychotics
o Use of these drugs in older patient with dementia is associated with
an increased risk of death
 Nursing assessment
o Past health history – repeated head trauma, stroke, previous CNS infection, family history of
dementia
o Functional health problems
 Poor personal hygiene
 Gait instability
 Inability to perform activities of daily living
 Frequent nighttime awakening
 Daytime napping
 Forgetfulness
 Difficulty with problem solving (early sign)
 Depression
 Withdrawal
 o Physical assessment findings
 Presence of agitation
 Loss of recent memory
 Disorientation to date and time
 Flat affect
 Impaired abstraction, cognition, and judgement
 Impaired ability to recognize close family and friends
 Loss of remote memory
 Confusion
 Inability to do simple tasks
 Incontinence
 Immobility
o Possible diagnostic findings
 Cerebral cortical atrophy on CT scan
 Poor scores on mental status tests (Mini-Cog)
 Hippocampal atrophy on MRI scan
 Abnormal changes on PET
 Health promotion
o Steps to keep the brain healthy:
 Avoid harmful substances – excessive drinking and drug abuse can damage brain
cells
 Challenge yourself by reading frequently and solving puzzles – keeping mentally
active strengthens brain connections and promotes new ones
 Exercise regularly
 Stay socially active
 Avoid trauma to the brain
 Treat depression – recognize and treat depression early; depression may cause or
worsen memory loss and other cognitive impairment
 Nursing interventions
o Assess for depression in patients recently diagnosed with Alzheimer’s disease –
antidepressant drugs and counseling may be indicated
o Assess family caregivers and their ability to accept and cope with the diagnosis
 Caregivers may also be in denial and may not seek medical attention early in the
disease
o Work collaboratively with the caregiver in monitoring and managing the clinical
manifestations of AD effectively as symptoms change over time
 Perform measures to decrease clinical manifestations and prevent harm (see next
major bullet point “Nursing care” for further details)
o Teach the caregiver to perform tasks that are required to manage the patient’s care
o Implement extra safety measures for patients with AD that are hospitalized for other health
problems
 Hospitalization can precipitate a worsening of the disease or delirium
 Patients with AD in an acute setting need to be observed more closely because of
concerns for safety, frequently orientated to place and time, and given reassurance
  Anxiety or disruptive behavior may be reduced by using consistent nursing staff
 Nursing care (in regard to symptom managing)
o Nursing care required by the patient with AD changes as the disease progresses,
emphasizing the need for regular assessment and support
 The severity of the problems and the amount of nursing care required intensify over
time
o Behavioral problems
 Assess the patient’s physical status and assess for factors that may precipitating the
behavioral problems
 Check for changes in vital signs, urinary and bowel patterns, and pain
 Also assess for environmental factors that may trigger behavioral problems
(eg. excessive noise, extremes in temperature)
 Disruptive behaviors may be treated with antipsychotic drugs, but these have
adverse side effects – all other measure of treating behavioral issues should be used
first before drugs are used
 Nursing strategies that address difficult behavior include redirection, distraction,
and reassurance
 Redirecting involves changing the patient’s focus onto another activity
 Ways to distract the patient may include providing snacks, listening to
favorite music, watching tv, looking at family photographs, or walking
 Reassurance involves communicating to the patient that he or she will be
protected from danger, harm, or embarrassment
 The use of repetitive activities, songs, poems, music, massage, aromas, or a favorite
object can be soothing to patients
 When a patient resists or pulls tubes or dressing, cover these items with stretch
tube gauze or remove them from the visual field
 Sundowning – a specific type of agitation that occurs when a patient becomes more
confused and agitated in the late afternoon or evening
 Behaviors commonly exhibited include agitation, aggressiveness,
wandering, resistance to redirection, and increased verbal activity such as
yelling
 May be caused by disruption of circadian rhythm, fatigue, unfamiliar
environment and noise, medications, reduced lighting, and sleep
fragmentation
 Interventions:
o Remain calm and avoid confrontation
o Assess situation for possible causes of agitation
o Create a quiet, calm environment
o Keep reorienting patient
o Maximize exposure to daylight
o Evaluate medications for side effects
o Limiting naps and caffeine
o Pain management
  Pain must be recognized and treated promptly because it can result in alterations in
the patient’s behavior
 If the AD patient has difficult expressing pain, rely on other cues
o Eating and swallowing difficulties
 Use pureed foods, thickened liquids, and nutritional supplements when chewing
and swallowing become problematic for the patient
 Patients may need reminders to chew their food and to swallow, and a quiet and
unhurried environment for eating
 Avoid distractions at mealtimes
 Provide easy-grip eating utensils and finger foods to allow self-feeds
 Offer liquids frequently
o Infection prevention
 Urinary tract infections and pneumonia are the most common infections in patient
with AD
 Any manifestations of infection, such as a change in behavior, fever, cough, or pain
on urination need prompt evaluation and treatment
o Elimination problems
 When possible, habit or behavioral retraining of bladder and bowel function may
help decrease episodes of incontinence
 Management constipation with increased dietary fiber, fiber supplements, and stool
softeners
 Patient teaching
o After the initial diagnosis, make the patient aware that the progression of the disease is
variable and effective management of AD may slow the progress of disease
o Encourage activities such as visiting with friends and family, listening to music, participating
in hobbies, and exercising
o Provide memory cues in the home, establish a routine, and determine a specific location
where essential items need to be kept
o Do not correct misstatements or faulty memory
o Get the person with AD to stop driving
o Teach the family and caregivers about expected behavioral problems and how to manage
them
 Behavior problems occur in most patients with AD and include repetitiveness
(asking the same question repeatedly), delusions, hallucinations, agitation,
aggression, altered sleeping patterns, wandering, and resisting care
 These behaviors are often the patient’s way of responding to pain,
frustration, anxiety, etc.
 Inform caregivers that these behaviors are not intentional and are often difficult to
control
 Help identify and reduce potential triggers
 Help develop strategies such as distraction and diversion to cope with behavioral
problems
o Provide a regular schedule for toileting to reduce incontinence
o Monitor diet and fluid intake to ensure adequacy
o Assist the caregiver in assessing the home environment for safety risks and recommend him
or her to take the following steps:
 Install door locks
 Have the stairwells well lit
 Handrails should be graspable
 Tack down carpet edges
 Remove throw rugs and extension cords
 Use nonskid mats in the tub or shower
 Install handrails in the bath and by the commode
 Label drawers and facets (hot and cold)
o Recommend the caregiver to register with the MedicAlert + Alzheimer’s Association Safe
Return program that helps locate individuals who wander from their homes
o Advise the patient and caregiver to initiate health care decisions, including advance
directives, while the patient has the capacity to do so – this can ease the burden for the
caregiver as the disease progresses
o Inform the patient and family about adult day care programs and long-term care facilities
 The common goals of all day care programs are to provide respite for the family,
and a protective and stimulating environment for the patient
 The person with AD may eventually need to be placed in a long-term care facility
with special units to care for persons with AD
 The Alzheimer’s unit is designed with an emphasis on safety – the unit is
usually secured so the patient can walk freely but not wander outside of it
o Work with the caregiver to assess stressor and to identify coping strategies to reduce the
burden of caregiving
 Determine what the caregiver views as the most disruptive or distressful to establish
the priorities of care
 Assess what the caregiver’s expectations regarding to the patient’s behavior
 Inform about support groups for caregiver and family members