Nursing 407 - Geriatric Healthcare
Chapter 8 – Impaired cognitive and affective function
Assessing mental status is complex
- Cognitive ability
- Level of consciousness
- Appearance, behavior
- Speech and language
- Mood
- Affect
- Perception
- Thought content
- Insight
- Judgment
Changes requiring evaluation
- Memory and intellectual difficulties
- Changes in sleep patterns
- Changes in sexual interest, capacity
- Fear of death
- Delusions
- Hallucinations
- Disordered thinking
- Changes in emotional expression
Principles for psychological assessment of the elderly
- Minimize the patient’s preoccupations: pain, comfort, elimination, adequate hearing and seeing
- Explain what you’re doing…and why
- Minimize distractions: quiet room, adequate lighting
- Speak slowly and clearly
- Takes breaks if necessary
Cognition vs affect
- Cognition
- Conscious intellectual activity
- Thinking
- Reasoning
- Remembering
- Affect
- A mental state
- Emotion
- Mood
- Feeling
Common disorders of the elderly
- Cognitive
- Dementia
- Cognitive
- Delirium
- Affective
- Depression
Delirium vs dementia
- Delirium
- Temporary mental confusion, agitation
- Disorientation
- Fluctuating consciousness
- Delusions
- Sleep-wake disturbances
- May be caused by fever, intoxication, shock
- Dementia
- Deterioration of intellectual capacities
- A syndrome, chronic and terminal
- Caused by organic disease or brain disorder
The syndrome of dementia
- Compromised ability to function at work or home
- Decline in usual abilities
- Not explained by other causes
- Verified by history and cognitive assessment
- Includes at least 2 of the following:
- Inability to acquire new information
- Impaired ability to manage complex tasks
- Inability to recognize
- Impaired language function
- Changes in personality
Types of dementia
- Alzheimer’s
- Vascular
- Lewy Body (Parkinson’s)
- Fronto-temporal
Comparison of types of dementia
- Alzheimer’s
- Most common form of dementia
- Causes include genetics, environment, lifestyle
- Vascular
- Second most common form
- Caused by cardiovascular factors
- Lewy body
- Protein bodies present in the brain
- Can occur late in Parkinson’s disease
- Frontotemporal
- Personality change
- Frontal brain atrophy occurring in mid-50s
- Older adults can have more than one type: mixed dementia
Mild cognitive impairment vs dementia
- Transition between normal aging and dementia
- Memory problems without deficits in ADLs
- Associated with increased risk of death
- If found in conjunction with depression, risk of converting to AD is greater
Alzheimer’s disease
- Before the 1950s, misidentified as alcoholism or some other presentation
- From ages 65 to 74, risk is about 2%
- Risk increases with age (42% at age 85)
- Risk increases with family history of AD
- Medical risks:
- Head trauma
- Diabetes
- Frailty
- High cholesterol
- Obesity
- Low physical activity
- Low vitamin D
- Clinical depression
Incidence of Alzheimer’s disease
- Twice as common in women
- Common in people whose mothers had the disease (the “maternal effect”)
- Age is greatest risk factor
- Associated with low education level
Cultural considerations
- Symptoms begin on average 7 years earlier in US Latinos than in non-Latino whites.
- Affects African Americans 3 times more than European Americans.
- Japanese American men have higher prevalence that Japanese men living in Japan.
Diagnosis of Alzheimer’s disease
- No definitive diagnostic test
- Physical examination
- Formal mental status exam
- Onset after age 40, most after age 65
- Postmortem examination of brain tissue is only way to confirm diagnosis
Prognosis of Alzheimer’s disease
- Cognitive decline is inevitable
- Average survival time from time of diagnosis is 7-8 years
- May last more than 20 years
Signs and symptoms of Alzheimer’s
- Brain changes may begin up to 20 years before symptoms are obvious
- Loss of short term memory is often the first sign
- Disease progresses gradually but may plateau for long periods of time
- Distinct symptoms for early, intermediate and late stages.
Mild Alzheimer’s disease (early-stage)
- Memory difficulties
- Spatial disorientation
- Learning and retaining new information becomes difficult
- Language difficulties (word finding)
- Mood swings—hostility, irritability, agitation
- Personality changes
- Progressive difficulty with activities of normal living
- Abstract thinking, insight, judgment impaired
Tasks at time of diagnosis
- Preparation for progressive decline
- Establishing DPAHC
- Establish interventions to address functional impairment
- Tasks apply to both family and patient!
Possible behaviors—mild Alzheimer’s
- Agitation
- Restlessness
- Irritability
- Confusion, disorientation
- Suspiciousness
- Yelling
- Pacing
- Violence
- Hallucinations
Sundowner syndrome
- Many patients with mild cognitive impairment or early Alzheimer’s develop this syndrome
- Behavioral changes that occur in later afternoon or evening
- Triggered by diminishing sunlight
- Less light, more shadows may cause fear, confusion
- Dreams and reality become blended
Caring for a patient with Sundowner’s
- Establish a routine
- Keep calm
- Discuss the source of agitation
- Provide for basic needs
Moderate Alzheimer’s disease (middle-stage)
- Aphasia
- Apraxia
- Confusion, inability to initiate meaningful activities
- Agitation
- Insomnia
- Remote memory reduced, but not lost
- May require help with basic ADLs
- Personality changes may progress
- Behavior problems may progress
- Sense of time and place is lost; wandering
- Risk of falls, accidents
- Disorganized sleep patterns
Severe Alzheimer’s disease (late-stage)
- Resistiveness to care
- Incontinence
- Eating difficulties
- Motor impairment
- Cannot walk, feed self, other ADLs
- Unable to swallow
- Recent and remote memory lost
- Problems include…
- Immobility
- Pressure ulcers
- Nutrition
Mental changes to anticipate
- Changes create increasingly difficult behavior….
- Depression
- Anxiety
- Hallucinations
- Paranoia due to:
- Confusion
- Inherent personality
- Unique coexisting mental disorder
- Brain physiological changes
Goals of treatment of dementia
- Treatment is focused on 4 areas:
- Safety and environmental measures
- Maintain physical/functional abilities
- Drugs
- Caregiver assistance
Patient safety
- Evaluate home for safety
- Signal monitoring systems for wandering
- Unplug the stove, remove the car, confiscate the keys
- Install alarms?
- Ultimately requires assistance or change in environment
- Patient care goals:
- Prevent accidents
- Manage behavior disorders
- Plan for change as disease progresses
- Transfer of responsibility…
- From patient to family…
- From family to others?
Maintaining functional abilities requires addressing specific behaviors
- Resistiveness
- Repetitiveness
- Sexual inappropriateness
- Aggression
- Food refusal
Non-medication management of resistiveness
- Task may be too difficult—break into small steps
- Caregiver impatience—allow ample time
- Can’t follow directions—simplify request
- Modesty causes embarrassment—respect privacy
- Fear of task—reassure, comfort, distract with music or conversation
Non-medication management of food refusal
- Make meal times a measure of the day’s progression
- Create an inviolable routine
- Incorporate patient preferences
- Eliminate any source of discomfort
- Maximize dense calories
- Use finger foods
- Avoid dry foods
- Keep patient upright
Non-medication management of inappropriate sexual behavior
- Misinterpreting caregiver interaction—no mixed sexual messages
- Decreased judgment, lack of social awareness—do not overreact, confront
- Uncomfortable—check for irritants
- Need for attention—increase basic need for touch and warmth, offer soothing objects
- Self-stimulating—offer privacy, remove from inappropriate place
Drugs for Alzheimer’s disease
- Minimize the use of drugs with CNS activity
- Sedation worsens dementia!
- Antipsychotics may be used to control behavior disorders (not Alzheimer’s disease itself)
- Signs of depression treated with anti-depressants (preferably SSRIs—Paxil, Zoloft, Lexapro)
- Mild to moderate disease—cholinesterase inhibitors (Donepezil [Aricept], Rivastigmine [Exelon])
- Moderate to severe disease—Memantine (Namenda)
Factors in caregiver burden
- Screaming
- Repetitive questions
- Verbal and physical aggression
- Reckless or careless behavior
- Personality clashes
- Not sleeping at night
- Wandering
- Suspiciousness
- Accusations
- Sexual actions
- Depression
- Resistance
Caregiver burden interventions
- Design strategies for sharing responsibility
- Emphasize importance of caring for oneself
- Allow for opportunities to discuss feeling of possible guilt
- Establish priorities
- Education regarding disease
- Support groups
- Caregiver respite
Terminal stage of Alzheimer’s disease
- Bedridden
- Dysphagia
- Eventually mute
- Completely dependent
- Risk of undernutrition, pneumonia, pressure ulcers
- Eventual death usually from infection
Issues associated with terminal stage
- Finding appropriate environment or facility
- Address guilt associated with transfer
- Important to discuss placement early on in process
- Address four important concepts:
- CPR (should not be offered)
- Transfer to acute care facility (not in patient’s best interest)
- Insertion of feeding tube (does not enhance quality of life)
- Treatment of infections (does not promote comfort)
Depression in the elderly
- Symptoms may be emotional and/or physical
- Apathy is common
- Multiple somatic complaints
- Chronic pain
- Older women 2x as susceptible
- Older men less likely to admit to depression
- Can be associated with medications
- Depression is common with dementia
Consider major depression with 4 or more
persisting for at least 2 weeks….
- Significant weight loss or gain, change in appetite
- Sleep disturbances
- Agitation, slowness
- Fatigue
- Feelings of worthlessness, guilt
- Inability to concentrate, make decisions
- Recurrent thoughts of suicide, death
- Hypochondriasis
Geriatric depression scale
- Long version—30 items
- Short version—15 items
- Can be used on healthy, ill, or those with cognitive impairment
- Patients who score >10 should be referred
Geriatric depression scale
- > 5 suggestive of depression
- > 10 depression very likely
Antidepressants commonly used in the care of the elderly depressed patient
- Selective serotonin reuptake inhibitors (SSRIs) have replaced tricyclic antidepressants (TCAs)
- Citalopram (Celexa)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Sertaline (Zoloft)
- Paroxetine (Paxil)
- Side effects include—
- CNS effects: agitation, anxiety, insomnia, sedation, headache; GI effects: N/V/D, anorexia; GU effects: sexual dysfunction, urgency; Respiratory effects: cough, dyspnea
Suicide
- 65 years+ have highest suicide rate of all ages
- Major risk is depression
- Older Caucasian males have highest death rates from suicide
- 70% of successful suicide attempts in older adults had seen primary physician within the previous month
- Consider any threat of suicide to be a valid threat
Risk factors for suicide
- Previous suicide attempt
- Alcohol or substance abuse
- Psychiatric illness
- Auditory hallucinations
- Living alone
- Guns at home
- Exposure to suicide
A note on schizophrenia
- The incidence of schizophrenia in the elderly is quite low
- The prevalence of schizophrenia in the elderly (> 65 years) estimated between 0.1% to 1%
- Approximately 35% of elderly patients treated in public psychiatric facilities have schizophrenia
- 12% of patients in nursing homes have schizophrenia
- A frequent feature of schizophrenia is auditory hallucinations
- Auditory hallucinations can trigger a suicide attempt