Medical Management PDF

10/24/23, 3:15 PM Realizeit for Student Medical Management In AD, the primary goal is to help maintain mental function as well as manage the cognitive and behavioral symptoms, and slow down the symptoms of the disease. Although there is no cure, several medications slow the progression of the dise...

10/24/23, 3:15 PM Realizeit for Student Medical Management In AD, the primary goal is to help maintain mental function as well as manage the cognitive and behavioral symptoms, and slow down the symptoms of the disease. Although there is no cure, several medications slow the progression of the disease. Cholinesterase inhibitors such as donepezil hydrochloride and rivastigmine tartrate, for example, enhance acetylcholine uptake in the brain, thus maintaining memory skills for a period of time. Cognitive ability may improve within 6 to 12 months of therapy. Rivastigmine is indicated for severe AD and it is recommended that treatment continue as long as possible (NIH, 2018b). Behavioral problems such as agitation and psychosis can be managed by behavioral and other interventions such as music therapy (Weise, Jakob, Töpfer, et al., 2018). Associated depression and behavioral problems can also be treated pharmacologically if other interventions fail. Because symptoms change over time, all patients with AD should be reevaluated routinely, and the nurse should document and report both positive and negative responses to medications. Nursing Management Nurses play an important role in the recognition of AD, particularly in hospitalized older adults, by assessing for signs (e.g., repeating or asking the same thing over and over). Nursing interventions for AD are aimed at promoting patient function and independence for as long as possible. Other important goals include promoting the patient’s physical safety, promoting independence in self-care activities, reducing anxiety and agitation, improving communication, providing for socialization and intimacy, promoting adequate nutrition, promoting balanced activity and rest, and supporting and educating family caregivers. These nursing interventions apply to all patients with AD, regardless of cause. Supporting Cognitive Function Because dementia of any type is degenerative and progressive, patients display a decline in cognitive function over time. In the early phase of dementia, minimal cuing and guidance may be all that are needed for the patient to function fairly independently for a number of years. However, as the patient’s cognitive ability declines, family members must provide more and more assistance and supervision. A calm, predictable environment helps people with dementia interpret their surroundings and activities. Environmental stimuli are limited, and a regular routine is established. A quiet, pleasant manner of speaking, clear and simple explanations, and the use of memory aids and cues help minimize confusion and disorientation and 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 may help patients maintain cognitive, functional, and social interaction abilities for a longer period. Physical activity and communication have also been demonstrated to slow some of the cognitive decline of AD. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 1/4 10/24/23, 3:15 PM Realizeit for Student Promoting Physical Safety A safe home and hospital environment allow the patient to move about as freely as possible and relieves the family of constant worry about safety. For the patient residing at home, in order to prevent falls and other injuries, all obvious hazards are removed and hand rails are installed. A hazard-free environment allows the patient maximum independence and a sense of autonomy. Adequate lighting, especially in halls, stairs, and bathrooms, is necessary. Nightlights are helpful, particularly if the patient has increased confusion at night, sometimes referred to as sundowning. Driving is prohibited, and smoking is allowed only with supervision. The patient may have a short attention span and be forgetful; therefore, the nurse and the family must be patient, repeat instructions as needed, and use reminders (i.e., post-it notes, electronic reminders) for daily activities. Doors leading from the house must be secured. Outside the home, all activities must be supervised to protect the patient, and the patient should wear some type of identification in case of separation from the caregiver. If the patient is hospitalized, additional precautionary measures should be taken. Wandering behavior, which may be worse in the hospital due to unfamiliar surroundings, can often be reduced by gentle persuasion, distraction, or by placing the patient close to the nursing station. Restraints should be avoided because they can increase agitation and lead to injury. Promoting Independence in Self-Care Activities Pathophysiologic changes in the brain make it difficult for people with AD to maintain physical independence. Patients should be assisted to remain functionally independent for as long as possible. One way to do this is to simplify daily activities by organizing them into short, achievable steps so that the patient experiences a sense of accomplishment. Frequently, occupational therapists can suggest ways to simplify tasks or recommend adaptive equipment. Direct patient supervision is sometimes necessary; however, 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. Reducing Anxiety and Agitation Despite profound cognitive losses, patients are sometimes aware of their diminishing abilities. Patients need constant emotional support that reinforces a positive self-image. When loss of skills occurs, goals are adjusted to fit the patient’s declining ability. The environment should be kept familiar and noise free. Excitement and confusion can be upsetting and may precipitate a combative, agitated state known as a catastrophic reaction (overreaction to excessive stimulation). The patient may respond by screaming, crying, or becoming abusive (physically or verbally); this may be the patient’s only way of expressing an inability to cope with the environment. When this occurs, it is important to remain calm and unhurried. Forcing the patient to proceed with the https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 2/4 10/24/23, 3:15 PM Realizeit for Student activity only increases the agitation. It is better to postpone the activity until later, even to another day. Frequently, the patient quickly forgets what triggered the reaction. Measures such as moving to a familiar environment, listening to music, stroking, rocking, or distraction may quiet the patient. Research suggests that the use of activities and music therapy, both individualized and in groups, help decrease agitation (Zhang, Cai, An, et al., 2017). Becoming familiar with a particular patient’s usual responses to certain stressors helps caregivers avoid stressful situations. Improving Communication To promote the patient’s interpretation of messages, the nurse 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. In the earlier stages of dementia, lists and simple written instructions that serve as reminders may be helpful. In later stages, the patient 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. Providing for Socialization and Intimacy Needs Because socialization with friends can be comforting, visits, letters, and phone calls are encouraged. Recreation is important, and people with dementia are encouraged to participate in simple activities. Realistic goals for activities that provide satisfaction are appropriate. Hobbies and activities such as walking, exercising, and socializing can improve quality of life. The nonjudgmental friendliness of a pet may provide stimulation, comfort, and contentment. Care of plants or 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. Promoting Adequate Nutrition Mealtime 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 good. Cueing may be necessary to encourage adequate nutrition and hydration. Food is cut into small pieces to prevent choking. Liquids may be easier to swallow if they are thickened. 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 https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 3/4 10/24/23, 3:15 PM Realizeit for Student patient. Forgetfulness, disinterest, dental problems, lack of coordination, overstimulation, and choking all serve as barriers to good nutrition and hydration. 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. Promoting Home, Community-Based, and Transitional Care The emotional burden on the families of patients with all types of dementia is enormous. The physical health of the patient is often very stable and the decline gradual. Family members may cling to the hope that the diagnosis is incorrect and that their relative will improve with greater effort. Family members provide at least 83% of the home care that is required by patients with AD (Alzheimer’s Association, 2019). They are faced with numerous difficult decisions (e.g., when the patient should stop driving, when to assume responsibility for the patient’s financial affairs). Aggression and hostility exhibited by the patient are often misunderstood by caregivers, who may feel unappreciated, frustrated, and angry. Feelings of guilt, nervousness, and worry contribute to caregiver fatigue, depression, and family dysfunction. Researchers have identified that a Web-based intervention can be effective in helping with anxiety and stress, reducing depressive symptoms, and identifying care needs and planning interventions that promote balance and congruence in the lives of caregivers (Ploeg, Markle-Reid, Valaitis, et al., 2017). Neglect or abuse of the patient can occur, and this has been documented in home situations as well as in institutions. If neglect or abuse of any kind—including physical, emotional, sexual, neglect, or financial abuse—is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it. The Alzheimer’s Association is a coalition of family members and professionals who share the goals of family support and service, education, research, and advocacy. Family support groups, respite (relief) care, and adult day care may be available through different community resources, such as the Area Agency on Aging, in which concerned volunteers are trained to provide structure to caregiver support groups (see Resources section at the end of module). Respite care is a commonly provided service in which caregivers can get away from the home for short periods while someone else tends to the needs of the patient. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IUFUzXhwrkmByRPKGm7XOkO3V8uhfXYXOmPZGy%2b… 4/4