Psychosocial Changes in Geriatrics PDF

# Psychosocial Changes ## Changes in Cognitive Ability - Changes in cognitive ability, excessive forgetfulness, and mood swings are not a part of normal aging. - Changes in mental status may be related to: - Alterations in diet - Fluid and electrolyte balance - Fever - Low oxygen le...

# Psychosocial Changes ## Changes in Cognitive Ability - Changes in cognitive ability, excessive forgetfulness, and mood swings are not a part of normal aging. - Changes in mental status may be related to: - Alterations in diet - Fluid and electrolyte balance - Fever - Low oxygen levels associated with many cardiovascular and pulmonary diseases - Cognitive changes may be reversible when the underlying condition is identified and treated. However, the susceptibility to depression, delirium and incidence of dementia increases with age. ## Common Psychosocial Changes: - **Retirement:** Adjusting to retirement can be challenging, leading to feelings of loss of purpose and identity. - **Loss of Loved Ones:** Grief and bereavement can significantly impact mental well-being. - **Social Isolation:** As social networks shrink, loneliness and isolation can become prevalent. - **Financial Concerns:** Financial insecurity can lead to stress and anxiety. - **Health Challenges:** Chronic illnesses and disabilities can impact self-esteem and quality of life. ## Mental Health Conditions: - **Depression:** - A common mental health condition in older adults. - Persistent sadness, loss of interest, and changes in sleep and appetite. - **Anxiety:** - Feelings of worry and apprehension triggered by various factors: health concerns, financial worries, or social isolation. - **Substance Abuse:** - Alcohol and drug abuse can be a coping mechanism for dealing with psychosocial stressors. ## Nursing Interventions for Psychosocial Changes: - **Social Support:** Encourage social interaction and participation in community activities. - **Emotional Support:** Provide a listening ear and offer empathy and validation. - **Stress Management:** Teach relaxation techniques and coping mechanisms. - **Mental Health Assessment:** Screen for depression, anxiety, and other mental health conditions. - **Referral to Specialists:** Refer patients to mental health professionals when necessary. # Depression - Common affective or mood disorder of old age. - Higher among the hospitalized elderly. - Often related to a chronic illness or pain, secondary to a medication interaction or an undiagnosed physical condition. - **Signs:** - Feelings of sadness, fatigue, diminished memory and concentration, feelings of guilt or worthlessness, sleep disturbances, appetite disturbances with excessive weight loss or gain, restlessness, impaired attention span, suicidal ideation. - Cognitive impairment resulting from depression is a result of apathy rather than a decline in brain function. ## Atypical Presentation - Older depressed patients often have different complaints and presentations than younger patients. - Less commonly experience "mood symptoms." - Often have more somatic symptoms and may end up hospitalized. ## Medications That Can Cause Depression - Anti-hypertensives: Beta Blockers, Clonidine - Anti-Parkinson's Medications: Carbidopa/Levodopa - Others: Benzodiazepines, Antihistamines, Barbituates # Depression: Who is at Risk? - **Female Gender** - **Divorced or Separated Status** - **Low Socioeconomic Status** - **Poor Social Support** - **Comorbid Illness** - **Cognitive Impairment** - **Adverse/Stressful Life Events** - **Family History** - **Prior Depressive Episodes** - **Previous Suicide Attempts** - **Financial Stress** ## Geriatric Depression: Risk Factors - History of Depression - Functional Disability - Illness - Family Criticism - Difficulty Performing Physical Activities # Depression in Elderly People - **Negative Thoughts** - **Tragic Incidents** - **Dementia** - **Anorexia** - **Inactivity** - **Social Isolation** - **Health Issues** - **Alcohol** - **Medication** # Stressors - Medical Illness - Family Problems - Work Problems - **Thoughts and Feelings** - Negative thoughts - Low Self-Esteem - Sadness - Hopelessness - **Physical Problems** - Poor Sleep - Pain - Low Energy - Poor Concentration - Poor Appetite - **Behavior** - Social withdrawal - Decrease in Activity - Decreased Productivity - Lack of Initiation # Alcohol and Drug Abuse - Related to depression and its incidence is significant in the elderly population. - Excessive drinking in people 55 to 64 years of age of all ethnic backgrounds has reportedly decreased from 12% to approximately 7% (CDC). - Dangerous in older people because of age-related changes in renal and liver function as well as the high risk of interactions with prescription medications and the resultant adverse effects. - Alcohol and drug abuse problems remain hidden. Patients may deny their habit when questioned. # Delirium - An acute confusional state. - Starts with confusion and progresses to disorientation. - Common and life-threatening complication for the hospitalized elderly. - Most frequent complication of hospitalization, occurring in 15% to 53% of older people postoperatively. - **Experience altered LOC from:** - **Stupor (Hypo Alert-Hypoactive):** Less problematic and difficult to diagnose. - **Excessive Activity (Hyper Alert- Hyperactive):** Demands more attention, easier to diagnose. - **Mixed:** Complicated and difficult to diagnose. - **Disorganized thinking** and **short attention span**. - May present with hallucinations, delusions, fear, anxiety, and paranoia. # Delirium: Attentive Clinical Assessment - Attentive clinical assessment is essential because delirium is sometimes mistaken for dementia. - Older adults are particularly vulnerable to acute confusion because of: - Decreased biologic reserve - The large number of medications they may take. - **RN implication:** Must recognize and report acute symptoms (unexpected onset and unknown underlying cause) - this is a medical emergency. - If the delirium goes unrecognized and the underlying cause is not treated, permanent, irreversible brain damage or death can follow. # Delirium: Causes - **Hypoxemia, metabolic derangements** - **Global impairment of cerebral metabolism** - **Drugs** - Neurotransmitter imbalance, disruption of synaptic communication - **Systemic inflammation** - Activation of primed microglia - Increased cytokine levels in the brain # Causes: - **Physical Illness:** Meds or alcohol toxicity, dehydration, fecal impaction, malnutrition, infection, head trauma, lack of environmental cues, sensory deprivation or overload. # Delirium: Prevention - Most effective strategy is **prevention**. Achievable in 30% to 40% of cases. - **Includes:** - Therapeutic activities for cognitive impairment. - Early mobilization. - Controlling pain. - Minimizing the use of psychoactive drugs. - Preventing sleep deprivation. - Enhancing communication methods (use eye glasses and hearing aids if needed). - Maintaining oxygen levels, fluids, and electrolyte balance. - Preventing surgical complications. # 10 Tips to Reduce Delirium in Elderly 1. Avoid Physical Restraints 2. Avoid Unnecessary Lines (IV, Foley, Monitors) 3. Avoid Benzodiazepines and Anticholinergics 4. Avoid Daytime Napping 5. Avoid NPO 6. Treat Pain Adequately 7. Treat Autonomic Dysreflexia (AD) and Stool Impaction 8. Maintain Patient's Mobility and Self-Care 9. Provide Eyeglasses and Hearing Aids 10. Involve Family to Reorient Patient - Reorient and mobilize the patient - Reduce sensory deprivation - Ensure the patient is hydrated - Implement a non-pharmacologic sleep regimen - Limit catheters and restraints. # Dementia: Don't Worry About Getting Older! - **Normal Age-Related Cognitive Changes:** - **Memory:** Some decline in short-term memory is normal with age, but long-term memory generally remains intact. - **Processing Speed:** The speed at which information is processed slows down, making it more challenging to learn new information. - **Attention:** Focus and concentration may become more difficult, especially in noisy environments. - **Executive Function:** Planning, problem-solving, and decision-making abilities may decline slightly. - **Pathological Cognitive Changes:** - **Dementia:** A progressive decline in cognitive function that interferes with daily activities. - **Alzheimer's Disease:** The most common type of dementia, characterized by amyloid plaques and neurofibrillary tangles in the brain. - **Vascular Dementia:** Caused by damage to blood vessels in the brain, leading to cognitive impairment. - **Lewy Body Dementia:** Characterized by Lewy bodies (abnormal protein deposits) in the brain, causing fluctuating cognition, visual hallucinations, and movement disorders. - **Parkinson's Disease Dementia:** A progressive neurodegenerative disorder that affects movement and can eventually lead to dementia. # Nursing Interventions for Cognitive Changes: - **Promote Cognitive Function:** Encourage mentally stimulating activities such as puzzles, reading, and social interaction. - **Memory Aids:** Provide memory aids like calendars, lists, and medication reminders. - **Safety Measures:** Ensure a safe environment to prevent falls and other injuries. - **Communication Strategies:** Use clear and concise language, provide ample time for processing information, and use visual aids. - **Support and Education:** Educate the patient and family about cognitive changes and available resources. # Dementia: A Collection of Symptoms - **Not a Normal Change of Aging:** Cognitive, functional, and behavioral changes that characterize dementia eventually destroy a person's ability to function. - **Symptoms are Usually Subtle in Onset:** Often progress slowly until they are obvious and devastating. - **2 Most Common Types of Dementia:** - **Alzheimer's Disease** (AD): 50% to 60% of cases - **Vascular or Multi-Infarct Dementia:** 10% to 20% of cases. # Other Non-Alzheimer Dementias Include: - Parkinson's disease, AIDS-related dementia, Pick's disease; these types of dementia account for fewer than 15% of cases. # Vascular Dementia - Formerly known as multi-infarct dementia, affects about 10% to 20% of people with dementia, and the rate is higher in men than women. - **Tends to have a more abrupt onset** than AD. - **Characterized by uneven, stepwise downward decline in mental function** associated with a vascular incident such as a subclinical stroke. - **Clinical course is unpredictable:** As a result, it is sometimes confused with AD, paranoia, or delirium. - **May be even more difficult to diagnose if the patient has vascular dementia as well as AD.** - **Associated with hypertension and CVD, risk factors (eg, hypercholesterolemia, hx of smoking, diabetes mellitus) are similar.** - **Prevention and management are also similar.** Therefore, measures to decrease BP & lower cholesterol levels may prevent future mini-infarcts. # 10 Warning Signs of Dementia - **Poor or Decreased Judgment** - **Changes in Mood or Behavior** - **Changes in Personality** - **Difficulty Doing Familiar Tasks** - **Problems Communicating** - **Confusion of Time and Place** - **Withdrawal from Work or Social Activities** - **Misplacing Things** - **Forgetfulness that Affects Day-to-Day Function** - **Difficulty Planning or Solving Problems** # Dementia Behaviors - **Early Stages** - **Difficulties with:** - Balancing a household budget - Planning and organizing - Managing medications - **Needed:** Cues and pointers will be needed to help the dementia-driven individual stay as independent as possible for the longest duration. - **Middle Stages:** - **Difficulties with:** Communication and the conduct of routine living activities become more difficult, and the caregivers can expect good days and days that are not as good. - **Required:** Incrementally greater levels of care and support. - **Late Stages:** - **Difficulties with:** - Fully lose their ability to communicate - Problems eating and swallowing - Susceptible to infections, most notably pneumonia # Alzheimer's Disease: A Complex Brain Disorder - **Complex brain disorder caused by a combination of various factors:** Genetics, neurotransmitter changes, vascular abnormalities, stress hormones, circadian changes, head trauma, and presence of seizure disorder. - **Begins Insidiously:** Gradual losses of cognitive function and disturbances in behavior and affect. - **Can Occur as Young as 40 Years Old:** Uncommon before 65 years old, but increases dramatically with increasing age, affecting as many as half of those 85 years of age and older. - **Not a Normal Part of Aging:** - Numerous theories – **the greatest risk factor for AD is increasing age, many environmental, dietary, and inflammatory factors also may determine whether a person suffers from this cognitive disease.** # Alzheimer's Disease: 2 Types - **Sporadic/Late-Onset AD:** - **Basis:** Typically after age 65. - **Prevalence:** Over 90% of all AD cases. - **Genetics:** APOE ε4 allele associated with increased risk, but no specific mutations. - **Family History:** No clear family link. - **Environmental & Lifestyle Factors:** Significant role: diet, exercise, smoking, head injuries, etc. - **Familial/Early-Onset AD:** - **Basis:** Typically before age 65, often in the 40s or 50s. - **Prevalence:** Less than 10% of all AD cases - **Genetics:** Specific genetic mutations often inherited, explaining the familial aspect. - **Family History:** Strong family history of AD, especially with multiple relatives diagnosed. - **Environmental & Lifestyle Factors:** Play a role, but genetics are the primary driver. # Alzheimer's Disease: Pathophysiology - **Gene might:** Influence a person's overall risk of developing the disease, influence some particular aspect of a person's risk (age at onset) - **Neuronal Damage:** Specific neuropathological and biochemical changes in the cerebral cortex - **Neurofibrillary tangles:** Tangled masses of nonfunctioning neurons. - **Senile or Neuritic Plaques:** Deposits of amyloid plaques - large protein in the brain - **Neuronal death**, **impaired protein functions** - **Decrease cells** that use the neurotransmitter acetylcholine are principally affected. - **Results in decreased brain size**. - **Impaired memory processing/cognitive problems.** # Alzheimer's Disease: Clinical Manifestations - **Cells within the brain (neurons) transport electrical messages to other parts of the body using chemical transmitters (neurotransmitters).** - **In Alzheimer's disease, areas of the brain tissue are damaged and some messages do not transmit, causing the symptoms of the disease.** - **Top 10 Early Signs:** - **Memory Loss** - **Changes in Mood** - **Misplacing Belongings** - **Hard to complete familiar task** - **Confusion of Time and Place** - **Social Withdrawal** - **Poor Judgment** - **Struggling to Communicate** - **Changes in Vision** ## Early Stages of AD: - **Forgetfulness and subtle memory loss occur.** - **Experience small difficulties in work or social activities but have adequate cognitive function to compensate for the loss and continue to function independently.** - **With further progression of AD, the deficits can no longer be concealed.** - **Forgetfulness:** - **May lose their ability to recognize familiar faces, places, and objects.** - **May become lost in a familiar environment.** - **Repeat the same stories because they forget that they have already told them.** - **Trying to reason with people with AD and using reality orientation becomes difficult, and word-finding difficulties occur...only increase their anxiety without increasing function.** # Alzheimer's Disease: Clinical Manifestations - **Ability to formulate concepts and think abstractly disappears.** - **Ex: Can interpret a proverb only in concrete terms.** - **Unable to recognize the consequences of their actions and therefore exhibit impulsive behavior.** - **Ex: On a hot day, a patient may decide to wade in the city fountain fully clothed** - **Difficulty with ADLs:** Operating simple appliances and handling money. - **Personality Changes** are also usually evident. May become depressed, suspicious, paranoid, hostile, and even combative. # All Types of Alzheimer's Disease Are Challenging. - **People need increasing amounts of support and care as the disease progresses.** - **This type of care is rarely covered by regular health insurance.** - **The person with the disease must eventually quit working.** - **The spouse often has to cut down working hours for care.** - **The hallmark of Alzheimer's care is the determination of how people can complete their activities of daily living (ADLs).** # Alzheimer's Disease: Clinical Manifestations - **Progression of the disease intensifies the symptoms.** - **Speaking skills deteriorate to nonsense syllables.** - **Agitation & physical activity increase.** - **Patients may wander at night.** - **Eventually, assistance is needed for most ADLs (eating & toileting due to development of dysphagia & incontinence).** # Terminal Stage of AD: - Patients are usually immobile and require total care (months/years). - Occasionally, patients may recognize family members or caregivers. - **Death: Result of complications... pneumonia, malnutrition, or dehydration.** # What to Expect in Late-Stage Dementia: - Bedbound, requires around-the-clock care. - Loss of facial expression. - Problems with everyday activities like bathing, dressing, eating. - Unable to speak. - Unable to walk or sit up without assistance. # 5 As to Alzheimer Diagnosis - **Anomia:** Inability to remember names of things. - **Apraxia:** Misuse of objects because of failure to identify them. - **Agnosia:** Inability to recognize familiar objects, tastes, sounds, and other sensations. - **Amnesia:** Memory loss, judgment, concentration, and attention. - **Aphasia:** Inability to express oneself through speech. # Alzheimer's Disease: Medical Management - **Primary Goal:** Manage the cognitive and behavioral Sx. - **No Cure & No Way to Slow the Progression of the Disease.** - **Cholinesterase Inhibitors (CEIs):** Donepezil hydrochloride (Aricept), rivastigmine tartrate (Exelon), galantamine hydrobromide (Razadyne), tacrine (Cognex). Enhance acetylcholine uptake in the brain, thus maintaining memory skills for a period; used for mild to moderate Sx. - **Donepezil and the Newest Med Memantine (Namenda):** Receptor agonist, can be used for management of moderate to severe symptoms. Cognitive ability may improve within 6 to 12 mos of Tx, but cessation of the meds results in disease progression and cognitive decline. - **Recommended that Tx continue** at least through the moderate stage of the illness. - **CEI + memantine:** May be useful for mild to moderate cognitive Sx. # Alzheimer's Disease: Medical Management - **Behavioral Problems:** - Agitation and psychosis can be managed by behavioral & psychosocial therapies. - Associated depression and behavioral problems can also be treated pharmacologically if other interventions fail. - Because symptoms change over time, all patients with AD who take medications should be reevaluated routinely. - Nurse should document and report both positive or negative responses to medications. # Alzheimer's Disease: Nursing Management - **Recognition of Dementia (Hospitalized Elderly):** Assessing for signs: - Repeating or asking the same thing over and over. - Getting lost during the nursing admission assessment. - **Nursing Interventions for Dementia aim to promote patient function and independence for as long as possible** - **Other important goals:** - Promoting physical safety and independence in self-care activities. - Reducing anxiety and agitation. - Improving communication. - Providing for socialization and intimacy. - Promoting adequate nutrition. - Promoting balanced activity and rest. - Supporting and educating family caregivers. - **These nursing interventions apply to all patients with dementia, regardless of cause.** # Dementia: RN Management: Supporting Cognitive Function - **Dementia:** Degenerative and progressive, patients display a decline in cognitive function over time. - **Early Phase of Dementia:** Minimal cuing and guidance is needed for the patient to function independently. - **Cognitive Ability Declines:** Family members must provide more and more assistance and supervision. - **Calm, predictable environment** helps patients interpret their surroundings and activities. - **Environmental Stimuli Are Limited:** A regular routine is established. Quiet, pleasant manner of speaking, clear and simple explanations. - **Use of Memory Aids and Cues** help minimize confusion and disorientation. - **Give patients a sense of security.** - **Prominently displayed clocks and calendars** may enhance orientation to time. - **Color-coding the doorway** may help patients who have difficulty locating their room. - **Active participation** helps maintain cognitive, functional, and social interaction abilities. - **Physical activity and communication** were demonstrated to slow some of the cognitive decline. # Dementia: RN Management: Promoting Physical Safety - **Safe home and hospital environment** allows the patient to move about as freely as possible and relieves the family of constant worry about safety. - **Prevent falls and injuries:** All obvious hazards are removed and handrails installed in the home. - **Hazard-free environment:** Allows patients maximum independence and sense of autonomy. - **Adequate lighting:** Halls, stairs, and bathrooms/Nightlights... helpful, particularly if the patient has increased confusion at night (sundowning). - **Driving is prohibited/smoking is allowed only with supervision:** Short attention span and forgetful. - **Wandering behavior can often be reduced by gentle persuasion or distraction.** - **Restraints should be avoided because they increase agitation.** - **Doors leading from the house must be secured.** - **Outside the home:** All activities must be supervised... to protect the patient; a patient wears an ID bracelet or neck chain in case of separation from the caregiver. # Dementia: Nursing Management - **Promoting Independence in Self-Care Activities:** - **Patients should be assisted to remain functionally independent for as long as possible.** - **Simplify daily activities** by organizing them into short, achievable steps so that the patient experiences a sense accomplishment. - **Direct patient supervision is sometimes necessary**, but maintaining personal dignity and autonomy is important for people with AD, who should be encouraged to make choices when appropriate and to participate in self-care activities as much as possible. # Dementia: RN Management: Reducing Anxiety and Agitation: - **Despite profound cognitive losses, patients are sometimes aware of their diminishing abilities.** Provide constant emotional support that reinforces a positive self-image. - **When loss of skills occurs, goals are adjusted to fit the patient's declining ability.** -# Keep environment & noise-free: Excitement & confusion can be upsetting...may precipitate a combative, agitated state (catastrophic reaction: overreaction to excessive stimulation) - **Pt may respond** by screaming, crying, or becoming abusive (physically or verbally). This may be the patient's only way of expressing an inability cope with the environment. - **RN to remain calm and unhurried.** Forcing the patient to proceed with the activity only increases the agitation... postpone the activity, even to another day... Frequently, the patient quickly forgets what triggered the reaction. - **Moving to a familiar environment, listening to music, stroking, rocking, or distraction may quiet the patient.** Structuring activity is also helpful. - **Becoming familiar with a particular patient's predicted responses to certain stressors helps caregivers avoid similar situations.** # Dementia: 9 Ways to Reduce Your Risk 1. Education 2. Physical Activity 3. Social Contact # Decreases: 1. Hearing Loss 2. Hypertension 3. Obesity 4. Smoking 5. Depression 6. Diabetes # Dementia: Nursing Management - **Improving Communication:** - To promote the patient's interpretation of messages, the RN should remain unhurried and reduce noises and distractions. - Use of clear, easy-to-understand sentences to convey messages is essential because patients frequently forget the meaning of words or have difficulty organizing and expressing thoughts. - **Earlier stages of dementia:** Lists and simple written instructions that serve as reminders may be helpful. - **Later stages:** Patients may be able to point to an object or use nonverbal language to communicate. - **Tactile stimuli**, such as hugs or hand pats, are usually interpreted as signs of affection, concern, and security. # Dementia: Nursing Management - **Providing for Socialization and Intimacy Needs:** - **Socialization with friends can be comforting:** Visits, letters, and phone calls are encouraged. - **Visits should be brief and non-stressful:** Limit visitors (1-2 at a time) helps reduce overstimulation. - **Recreation is important:** Patients with dementia are encouraged to participate in simple activities. - **Realistic goals for activities that provide satisfaction are appropriate.** - **Nonjudgmental friendliness of a pet** may provide stimulation, comfort, and contentment. - **Care of plants or of a pet** can also be satisfying and an outlet for energy. - **AD does not eliminate the need for intimacy.** Patients and their spouses may continue to enjoy sexual activity. Spouses should be encouraged to talk about any sexual concerns, and sexual counseling may be necessary. **Simple expressions of love, such as touching and holding, are often meaningful.** # Dementia: Nursing Management - **Promoting Adequate Nutrition:** - Mealtimes can be a pleasant social occasion or a time of upset and distress, and it should be kept simple and calm, without confrontations. - **Patients prefer familiar foods** that look appetizing and taste go - **To avoid any "playing" with food**, one dish is offered at a time. Food is cut into small pieces to prevent choking. - **Liquids may be easier to swallow** if they are converted to gelatin. - **Hot food and beverages are served warm,** and the temperature of the foods should be checked to prevent burns. - **When lack of coordination interferes with self-feeding, adaptive equipment is helpful.** Some patients may do well eating with a spoon or with their fingers. - **If this is the case, an apron or a smock**, rather than a bib, is used to protect clothing. - **As deficits progress, it may become necessary to feed the patient.** Forgetfulness, disinterest, dental problems, lack of coordination, overstimulation, and choking all serve as barriers to good nutrition and - **hydration.** # Dementia: Nursing Management - **Promoting Balanced Activity and Rest:** - **Many patients with dementia exhibit sleep disturbances, wandering, and behaviors that may be considered inappropriate.** These behaviors are most likely to occur when there are unmet underlying physical or psychological needs. - **Caregivers must identify the needs of patients who are exhibiting these behaviors** because further health decline may occur if the source of the problem is not corrected. - **Adequate sleep and physical exercise are essential.** If sleep is interrupted or the patient cannot fall asleep, music, warm milk, or a back rub may help the patient relax. - **During the day, patients should be encouraged to participate in exercise** because a regular pattern of activity and rest enhances nighttime sleep. **Long periods of daytime sleeping are discouraged.** # Summary of Differences Between Dementia and Delirium - **Alzheimer's Disease** - **Duration:** 2-20 years - **Symptom Progress:** Onset insidious. Early, mild, and subtle. Middle and late-intensified. Progression to death (infection or malnutrition) - **Mood:** Early depression (30%) - **Speech & Language:** Speech remains intact until late in the disease. Early-mild anomia (cannot name objects); deficits progress until speech lacks meaning; echoes and repeats words and sounds; mutism. - **Physical Signs:** Early-no motor deficits; middle-apraxia (70%) (cannot perform purposeful movement); late-Dysarthria (impaired speech); end stage-loss of all voluntary activity; positive neurologic signs - **Vascular (Multi-Infarct) Dementia** - **Duration:** Variable, years - **Symptom Progress:** Depends on location of infarct and success of treatment; death due to underlying CV disease. - **Mood:** Labile: mood swings - **Speech and Language**: May have speech deficit/aphasia depending on location of lesion. - **Physical Signs:** According to location of lesion: focal neurologic signs, seizures. Commonly exhibits motor deficits. - **Delirium:** - **Duration:** Lasts 1 day to 1 month. - **Symptom Progress:** Symptoms are fully reversible with adequate treatment; can progress to chronicity death if underlying condition is ignored. - **Mood:** Variable - **Speech & Language:** Fluctuating: often cannot concentrate long enough to speak. - **Physical Signs:** May be somnolent. Signs and symptoms of underlying disease. # Summary of Differences Between Dementia and Delirium - **Orientation:** - **Alzheimer's Disease:** Becomes lost in familiar places (topographic disorientation). Has difficulty drawing three-dimensional objects (visual and spatial disorientation). Disorientation to time, place, and person with disease progression. - **Vascular (Multi-Infarct) Dementia:** Loss is an early sign of dementia; loss of recent memory is soon followed by progressive decline in recent and remote memory. - **Delirium:** May fluctuate between lucidity and complete disorientation to time, place and person. - **Memory:** - **Alzheimer's Disease:** Loss is an early sign of dementia; loss of recent memory is soon followed by progressive decline in recent and remote memory. - **Vascular (Multi-Infarct) Dementia:** Impaired recent and remote memory; may fluctuate between lucidity and confusion. - **Delirium:** Impaired recent and remote memory; may fluctuate between lucidity and confusion. - **Personality** - **Alzheimer's Disease:** Apathy, indifference, irritability. Early disease-social behavior intact; hides cognitive deficits. Advanced disease-disengages from activity and relationships suspicious, paranoid delusions caused by memory loss, aggressives, catastrophic reactions. - **Vascular (Multi-Infarct) Dementia:** Fluctuating, cannot focus attention to converse; alarmed by symptoms (when lucid); hallucinations paranoid. - **Delirium:** Highly impaired; cannot maintain or shift attention. - **Functional status, activities of daily living:** - **ALzheimer's Disease:** Poor judgment in everyday activities has progressive decline in ability to handle money, use the telephone, function in the home and workplace. - **Vascular (Multi-Infarct) Dementia:** Highly impaired. - **Delirium:** Impaired. - **Attention Span:** - **Alzheimer's Disease:** Distractible, short attention span. - **Vascular (Multi-Infarct) Dementia:** Highly impaired; cannot maintain or shift attention. - **Delirium:** Variable alternates between high agitation, hyperactivity, restlessness, and lethargy. - **Psychomotor Activity:** - **Alzheimer's Disease:** Wandering, hyperactivity, pacing restlessness, agitation. - **Vascular (Multi-Infarct) Dementia:** Fluctuating, stepwise progression. - **Delirium:** Variable alternates between high agitation, hyperactivity, restlessness, and lethargy. - **Sleep-Wake Cycle:** - **Alzheimer's Disease:** Often impaired; wandering and agitation at nighttime. - **Vascular (Multi-Infarct) Dementia:** Hypoalert-hypoactive, Hyperalert-hyperactive, Mixed hypo-hyper. - **Delirium:** Takes brief naps throughout the day and night. # Care Study - **Ms. Wallace is a 65-year-old woman with multiple sclerosis who is currently ventilator and feeding tube dependent. Her two sons are attempting to have her code status changed to DNR/DN. However, her daughter is fighting to maintain her at full code status. Ms. Wallace had appointed her husband as her health care proxy 5 years ago, but unfortunately he passed away 6 months ago. The client now is incapable of communicating her wishes, although each family member states that they know what she would want in this situation. You are a nurse in her nursing home, and you have been taking care of her regularly for the past month. You have established a relationship with each member of her family and have spoken to each of them regarding their feelings surrounding the situation. Several family meetings have been held, but as of yet no compromise has been made. Her physician comes to you to discuss how this issue may be resolved.** # Dying Person's Bill of Rights - **I have the right to be treated as a living human being until I die.** - **I have the right to maintain a sense of hopefulness, however changing its focus may be.** - **I have the right to be cared for by those who maintain a sense of hopefulness, however challenging this might be.** - **I have the right to express my feelings and emotions about my approaching death, in my own way.** - **I have the right to participate in decisions concerning my care.** - **I have the right to expect continuing medical and nursing attention even though "cure" goals must be changed to "comfort" goals.** - **I have the right not to die alone.** - **I have the right to be free from pain.** - **I have the right to have my questions answered honestly.** - **I have the right not to be deceived.** - **I have the right to have help from and for my family accepting my death.** - **I have the right to die in peace and dignity.** - **I have the right to retain my individuality and not be judged for my decisions, which may be contrary to the beliefs others.** - **I have the right to discuss and enlarge my religious and/or spiritual experiences regardless of what they may mean to others.** - **I have the right to expect that the sanctity of the human body will be respected after death.** - **I have the right to be cared for by caring, sensitive, knowledgeable people who will attempt to understand my needs and will be able to gain some satisfaction in helping me face my death.** # Cultural Views of Death - **Native Americans:** Death is viewed in a circular pattern rather than linear. - **African Americans:** Prior bad memories of health care make older adults concerned about making end-of-life decisions. - **Asian Americans:** End-of-life care decisions may be made by family members who consider it their role, even if the older adult is competent to make decisions. This may also involve the nondisclosure of terminal illness to protect the older adult. Autopsy and organ donation are not acceptable, so as not to disturb the body. - **Latin Americans:** Reluctance to make decisions on end-of-life issues or complete advance directives, as well as endorse the withholding or withdrawal of life-prolonging treatment, use of hospice services, support physician-assisted death, and organ donation is common. The well-being of the family may be considered over the well-being of the client. # End-Of-Life Care (EOLC) - **Support & medical care given during the time surrounding death.** - **As the global population ages, nursing professionals must be equipped with the knowledge and skills necessary to provide compassionate and holistic care for older adults at the end of their lives.** # Challenges in End-Of-Life Care for Older Adults - **Multimorbidity:** Many older adults have multiple chronic conditions (heart disease, DM, dementia) complicate treatment decisions and symptom management. - **Cognitive Decline:** Conditions like dementia often make it difficult for individuals to communicate their wishes or participate in decision-making. - **Frailty:** Frail elderly patients may have less physiological reserve to tolerate treatments, and managing frailty is a critical part of EOLC. # End of Life: Palliative Care - **Goal:** To allow older adults to die in a manner that they would consider a "good death". - **WHO defines palliative care** as *the active total care of patients whose disease is not responsive to curative treatment. Control of pain, other symptoms, and psychological, social, and spiritual problems is paramount.* - **Underscores the multidimensional nature of end-of-life care** with biological, psychological, social and spiritual components. # End-Of-Life Care: Undergone a Great Deal of Research - **As one approaches the end of life, one may explore the meaning of life and question the possibility of an afterlife.** - **Many aspects:** Communication, physical care, spiritual care, emotional and psychological care, as well as working with the family in promoting effective grieving. <start_of_image> breakdowns between palliative care and hospice care are # Palliative Care - **Chronic Life-Limiting Disease:** - **Active Treatment** - **Advance Care Planning** - **EOL/CMO** - **