Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition PDF

Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition Veronique Boscart, Lynn McCleary, Linda Sheiban Taucar, Theris A. Touhy, Kathleen Jett Chapter 21 Cognitive Impairment  Learning Objectives (1 of 2) Upon completion of this chapter...

Ebersole and Hess' Gerontological Nursing & Healthy Aging in Canada 3rd Edition Veronique Boscart, Lynn McCleary, Linda Sheiban Taucar, Theris A. Touhy, Kathleen Jett Chapter 21 Cognitive Impairment  Learning Objectives (1 of 2) Upon completion of this chapter, the reader will be able to: Differentiate between dementia, delirium, and depression. Discuss the different types of dementia and appropriate diagnosis. Describe nursing models of care for persons with dementia and cognitive impairment. 1-3  Learning Objectives (2 of 2) Upon completion of this chapter, the reader will be able to: Discuss common concerns in caring for persons with dementia. Develop a nursing care plan for a person with delirium. Develop a nursing care plan for a person with dementia. 1-4 Overview of Cognitive Impairment Cognitive Assessment An older adult with a change in cognitive function needs a thorough assessment to identify the presence of specific pathological conditions. It is important for nurses to have the skills to recognize cognitive impairment and monitor cognitive functioning. Considerations in Cognitive Impairment Stressful experience for older adults Can be perceived as “intrusive, intimidating, fatiguing, and offensive” Timing is also important 21-5  The Three Ds Delirium, dementia, and depression Not normal consequences of aging Can be difficult to diagnose Delirium characterized by a rapid onset, usually over hours or days Dementia usually has a gradual onset; slow, steady pattern of decline See Table 21-1: Differentiating Delirium, Depression and Dementia. 21-6  Screening for Cognitive Impairment Components of a Cognitive Tools available include: Assessment are: Geriatric Depression Scale LOC (GDS) Orientation to person, Mini-Mental State Exam place, and time (MMSE) Memory assessment (various types) Clock Drawing Test (CDT) Attention and concentration Mini-Cognition (Mini-Cog) Abstract reasoning Confusion Assessment Problem solving Method (CAM and CAM- ICU) 21-7  Delirium Characterized by a rapid onset and fluctuating course Symptoms include disturbances in consciousness and attention and changes in cognition Etiology Thought to be related to disturbances in the neurotransmitters in the brain that modulate the control of cognitive function, behaviour, and mood Poor cerebral blood flow Usually a complication of a medical illness, a medication or substance effect on the brain, or a surgical procedure involving general anaesthesia 21-8  Delirium: Incidence, Prevalence and Recognition A prevalent and serious disorder that occurs in older adults across the continuum of care It may affect up to 20% of older adults in the ED, more than 50% of older adults in hospital and as many as 90% of older adults in ICU. Often, delirium is not recognized by health care providers. Factors contributing to the lack of recognition: Inadequate education about delirium Lack of formal assessment methods Ageist attitudes 21-9  Risk Factors for Delirium (1 of 2) Predisposing factors Demographic characteristics (age 65 years or older, male sex) Cognitive status (dementia, cognitive impairment, history of delirium, depression) Functional status (dependence, immobility, low level of activity, history of falls) Sensory impairment (visual, hearing) Decreased oral intake (dehydration, malnutrition) Medications (multiple psychoactive medications, many medications, alcohol abuse) Co-existing medical conditions 21-10  Risk Factors for Delirium (2 of 2) Precipitating factors Medications (sedative hypnotics, narcotics, anticholinergic medications, multiple medications, alcohol or medication withdrawal) Primary neurological diseases (stroke, intracranial bleeding, meningitis, or encephalitis) Intercurrent illnesses (infections, iatrogenic complications, severe acute illness, hypoxia, shock, fever or hypothermia, anemia, dehydration, poor nutritional status, low serum albumin level, metabolic derangements such as electrolyte or acid–base) Surgery (orthopedic, cardiac, prolonged cardiopulmonary bypass, noncardiac) Environmental (admission to ICU, physical restraints, bladder catheter, multiple procedures) Pain Emotional stress Prolonged sleep deprivation 21-11  Clinical Subtypes and Consequences of Delirium Clinical subtypes of delirium: Hypoactive Hyperactive Mixed Consequences of delirium Significant distress for everyone involved, including the patient High morbidity and mortality Functional decline Increased postoperative complications Increased length of hospital stay and hospital readmissions Increased services after discharge Long-term cognitive decline High rates of institutionalization 21-12  Implications for Gerontological Nursing and Healthy Aging Assessment Determine the person’s usual mental status. Conduct a formal assessment to identify possible delirium when admitted to the hospital. Complete the Confusion Assessment Method (CAM) routinely. Intervention: should be targeted toward individual risk factors Nonpharmacological Hospital Elder Life Program (HELP) has shown great success Pharmacological Caregiving Strategies: Refer to Fig. 21.1 21-13  Overview of Dementia An irreversible state that progresses over years Incidence and prevalence: Alzheimer’s type is the most common type. About 1% of Canadians between 65 and 69 years have dementia, while the prevalence is 25% for those older than 85 years. By 2030, over 912,000 will have Alzheimer’s. Prevalence increases with age. Clinical features Aphasia Apraxia Agnosia Disturbances in executive functioning (planning, organizing, sequencing, abstracting) 21-14  Types of Dementia Primary Progressive disorders caused by pathological conditions of the brain Secondary Produce pathological conditions of the brain as a result of other conditions Mixed Combination of Alzheimer’s disease, vascular brain changes, prior alcoholism 21-15  Alzheimer’s Disease A cerebral degenerative disorder of unknown origin Destroys proteins of nerve cells in the cerebral cortex by diffuse infiltration with nonfunctional tissue called neurofibrillary tangles and plaques. The brain shrinks to about one-third of its normal weight. The tangles consist of a protein, called tau, that “clogs” the insides of brain cells and their connections. Typical life expectancy is 8 to 9 years after symptom onset. 21-16  Alzheimer's Disease: Diagnosis The only confirmatory method of diagnosing AD is to perform a brain biopsy or autopsy. Probable AD can be clinically diagnosed: If the onset is typically insidious with progression If no other systemic or brain diseases could account for the progressive cognitive deficits Symptoms are usually present several years before a diagnosis is made. 21-17  Alzheimer's Disease: Cultural Differences Research indicates that some ethnic minorities are under-represented in seeking and receiving services for dementia. Other factors influence access to services, including language barriers, stigma, lack of knowledge about dementia and available resources, and hesitancy to use services viewed as culturally incongruent. Development of culturally and linguistically appropriate sources of information about dementia is important. 21-18  Alzheimer's Disease: Medication Treatment Cholinesterase inhibitors (ChEIs) donepezil (Aricept) rivastigmine (Exelon) galantamine (Reminyl) N-methyl-D-aspartate (NMDA) antagonist memantine (Ebixa) 21-19  Vascular Dementia A group of heterogeneous disorders arising from cerebrovascular insufficiency or ischemic or hemorrhagic brain damage More common among people from Africa and South Asia Associated with advancing age, male gender, and stroke Often co-exists with Alzheimer’s dementia 21-20  Lewy Body Dementia Most common form of degenerative dementia; widely underdiagnosed A spectrum of disorders including dementia with Lewy bodies (DLB), and Parkinson’s disease dementia (PDD) Treatment No medications have been approved specifically for the treatment of LBD, but cholinesterase inhibitors are used and can offer symptomatic benefits. Symptoms Cognitive fluctuations Unpredictable changes in concentration and attention Hallucinations Parkinson symptoms REM Sleep Behaviour Disorder Severe sensitivity to neuroleptics 21-21  Frontotemporal Dementia A clinical syndrome associated with shrinking of the anterior frontal and temporal lobes of the brain Mean age of onset is between 52 to 56 years; often present in other family members Symptoms Changes in personality Inappropriate or bizarre social behaviour Treatments Aimed at managing behavioural symptoms, compensating for functional decline, and supporting family carers 21-22  Implications for Gerontological Nursing and Healthy Aging (1 of 2) Person-Centred Care Looks beyond the disease and the tasks we must perform to the person within and our relationship with them The focus is not on what we need to “do to the person” but rather on the person and how to enhance well- being and quality of life. See Box 21-6: General Nursing Interventions in Care of Persons with Dementia 21-23  Implications for Gerontological Nursing and Healthy Aging (2 of 2) Four Nursing Models of Care: for persons with dementia 1. Progressively Lowered Stress Threshold (PLST) model 2. Need-Driven, Dementia-Compromised Behaviour Model (NDB) 3. Recognition of Retained Abilities Model 4. Relating Well Model Staying with the resident during the care episode Altering the pace of care by recognizing the person’s rhythm and adapting to it Focusing care beyond the task 21-24  Interventions (1 of 2) Pharmacological and Nonpharmacological Treatment of Behaviour Expressions in Dementia: Medications should not be the first or even second line of response. The focus must be on understanding that behavioural expressions communicate distress and the response is investigating the possible sources of distress and intervening. Therapeutic Activities Meaningful and enjoyable activities provide cognitive stimulation and opportunities for interaction with others Enhance feelings of self-worth, promote a sense of belonging and accomplishment, and encourage expression of feelings and thoughts 21-25  Interventions (2 of 2) Exercise Maintain or improve function Prevent excess disability Improve mood Exercise has positive benefits for all older persons, regardless of condition or setting Pain assessment and treatment All evidence-based recommendations endorse beginning with a comprehensive assessment of the behaviour, yet 20% of Canadian older persons living in LTC were prescribed antipsychotics. 21-26  Interventions for Mild Cognitive Impairment (MCI) & Early Stage Memory Loss Earlier diagnosis provides opportunities to begin pharmacological and psychosocial interventions that may lessen the devastation of the disease for both patients and families. Three primary emotional challenges for family carers in the early stage: 1. Accepting the diagnosis 2. Accepting the prognosis 3. Relinquishing the relationship as it was previously known Common care concerns Nutrition, ADLs, maintenance of health and function, safety, communication, caregiver needs 21-27  Providing Care for ADLs Know the person’s lifetime bathing routines and preferences. Provide care only when the person is receptive. Respect refusals to participate in care; explain all actions. Realize that a bath is not an essential intervention. Encourage self-care to the extent possible; make bathrooms and shower areas warm, comfortable, and safe. Be attentive to pain and discomfort; use alternative bathing methods such as a towel bath or sponge bath. 21-28  Wandering (1 of 3) Wandering can lead to falls, elopement (leaving the home or facility), disturbances in care routines such as eating, and interference with the privacy of others. Wandering behaviours can be predicted through careful observation and knowing the person’s patterns. Interventions for wandering or exiting behaviours: Face the person, and make direct eye contact (unless this is interpreted as threatening). Gently touch the person’s arm, shoulder, back, or waist if he or she does not move away. Call the person by his or her formal name (e.g., Mr. Jones). Listen to what the person is communicating verbally and nonverbally; listen to the feelings being expressed. 21-29  Wandering (2 of 3) Interventions for wandering or exiting behaviours (cont’d): Identify the agenda, the plan of action, and the emotional needs the agenda is expressing. Respond to the feelings expressed, staying calm. Repeat specific words or phrases, or state the need or emotion (e.g., “You need to go home; you’re worried about your husband.”). If such repetition fails to distract the person, accompany him or her and continue talking calmly, repeating back phrases and the emotion you identify. Provide orienting information only if it calms the person. If it increases distress, stop talking about the present situations. Do not “correct” the person or belittle his or her agenda. 21-30  Wandering (3 of 3) Interventions for wandering or exiting behaviours (cont’d): At intervals, redirect the person toward the facility or the home by suggesting, “Let’s walk this way now” or “I’m so tired; let’s turn around.” If orientation and redirection fail, continue to walk, allowing the person control but ensuring safety. Make sure you have a backup person, but he or she should stay out of eyesight of the person. Have someone call for help if you are unable to redirect. Usually the behaviour is time-limited because of the person’s attention span and the security and trust between you and the person. Register the person in a program such as Safely Home® and have a plan in case the person becomes lost. 21-31  Environmental Alterations and Family Caregiving Environmental Alterations Both home and institutional settings can be modified to be more supportive for people with dementia. Many facilities have established special care units (SCUs), designed for the needs of people with dementia. Family Caregiving Caregivers of people with dementia experience more adverse consequences than caregivers of those with other chronic illnesses. They are more likely to experience depression and health problems than other caregivers. 21-32  Family Caregiving for Persons with Dementia Most Canadians with dementia live in the community. 85% of Canadians with dementia rely on family or friends for care, averaging 26 hours per week of caregiving and about $4,600 per year in out-of- pocket expenses. Caregiver intervention programs that include bundled interventions are effective. Caregivers continue to provide care even if/once the person with dementia moves into LTC. 21-33