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Alzheimer’s disease (AD) The most common type of dementia that typically affects people older than 65 years. agnosia Loss of sensory comprehension, including facial recognition. amnesia Loss of memory. anomia An inability to find words. aphasia Problems with speech (expressive aphasia) and/or langua...

Alzheimer’s disease (AD) The most common type of dementia that typically affects people older than 65 years. agnosia Loss of sensory comprehension, including facial recognition. amnesia Loss of memory. anomia An inability to find words. aphasia Problems with speech (expressive aphasia) and/or language (receptive aphasia). apraxia Inability to use words or objects correctly. aura A sensation (e.g., visual changes) that signals the onset of a migraine headache or seizure. bradykinesia/akinesia Slow movement/no movement. clonus Rhythmic jerking of all extremities during a seizure. dementia (sometimes referred to as a chronic confusional state or syndrome) A general term for progressive loss of brain function and impaired cognition; there are many types of dementia. dyskinesia The inability to perform voluntary movement. encephalitis An infection (usually viral) of brain tissue and often the surrounding meninges. epilepsy (as defined by the National Institute of Neurological Disorders and Stroke) A chronic disorder in which repeated unprovoked seizure activity occurs. Huntington disease A rare hereditary disorder that is characterized by progressive dementia and choreiform movements (uncontrollable rapid, jerky movements) in the limbs, trunk, and facial muscles. meningitis An infection of the meninges of the brain and spinal cord, specifically the pia mater and arachnoid. migraine headache A common clinical syndrome characterized by recurrent episodic attacks of head pain that serve no protective purpose. nystagmus An involuntary condition in which the eyes make repetitive uncontrolled movements. Parkinson disease (PD)(also referred to as Parkinson’s disease and paralysis agitans) A progressive neurodegenerative disease that affects mobility and is characterized by four cardinal symptoms (also referred to as Parkinson’s disease and paralysis agitans) A progressive neurodegenerative disease that affects mobility and is characterized by four cardinal symptomstremor, muscle rigidity, bradykinesia/akinesia (slow movement/no movement), and postural instability. phonophobia A sensitivity to sound. photophobia A sensitivity to light. seizure An abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain that may result in a change in level of consciousness (LOC), motor or sensory ability, and/or behavior. status epilepticus A medical emergency and is a prolonged seizure lasting longer than 5 minutes or repeated seizures over the course of 30 minutes. validation therapy Recognition and acknowledgement of a patient’s feelings and concerns. vascular dementia The second most common type of dementia caused by disorders that decrease blood flow to parts of the brain. Priority and Interrelated Concepts The priority concepts for this chapter are: Cognition Mobility The Cognition concept exemplar for this chapter is Alzheimer’s Disease. The Mobility concept exemplar for this chapter is Parkinson Disease. The interrelated concepts for this chapter are: Pain Infection Neurologic disorders can interfere with self-management and functional ability; many of them cause impaired cognition, decreased mobility, and persistent pain. Infection can also cause neurologic problems. Chapter 3 briefly reviews these health concepts. Care of patients with health problems affecting the brain requires coordination by nurses and interprofessional collaboration. Cognition Concept Exemplar: Alzheimer’s Disease Pathophysiology Review Dementia, sometimes referred to as a chronic confusional state or syndrome, is a general term for progressive loss of brain function and impaired cognition; there are many types of dementia. Alzheimer’s disease (AD) is the most common type of dementia that typically affects people older than 65 years. Vascular dementia, such as multi-infarct dementia, results from strokes or other vascular disorders that decrease blood flow to parts of the brain. Table 39.1 compares AD with vascular dementia, the second most common type of dementia. Any type of dementia affects a person’s ability to learn new information and eventually impairs language, judgment, and behavior. As the disease progresses, the patient’s functional ability declines and death occurs as a result of complications of decreased mobility. Dementia is not a normal physiologic change of aging. The brain of the older adult usually weighs less and occupies less space in the cranium than does the brain of a younger person. Other changes in the brain that occur with aging include widening of the cerebral sulci, narrowing of the gyri, and enlargement of the ventricles. In the presence of AD and other types of dementia, these normal changes are greatly accelerated. Brain weight is reduced further. Marked atrophy of the cerebral cortex and loss of cortical neurons occur. Microscopic changes of the brain found in people with AD include neurofibrillary tangles, amyloid-rich senile or neuritic plaques, and vascular degeneration. Neurofibrillary tangles are composed of fibrous tissue that impairs the ability of impulses from being transmitted from neuron to neuron (McCance et al., 2019). Neuritic plaques are composed of degenerating nerve terminals and are found particularly in the hippocampus, an important part of the limbic system. Deposited within the plaques are increased amounts of an abnormal protein called beta amyloid. These proteins have a tendency to accumulate and form the neurotoxic plaques found in the brain that impair neuronal transmission (McCance et al., 2019). Although vascular degeneration occurs in the normally aging brain, its presence is significantly increased in patients with dementia. Vascular degeneration accounts for at least partial loss of the ability of nerve cells to function properly. This pathologic change contributes to the cognitive decline and mortality associated with AD. In addition to the structural changes in the brain associated with this disorder, abnormalities in the neurotransmitters (acetylcholine [ACh], norepinephrine, dopamine, and serotonin) may occur. High levels of beta amyloid can reduce the amount of acetyltransferase in the hippocampus. This loss is important because the decrease in Ach interferes with cholinergic innervation to the cerebral cortex. This change results in impaired cognition, recent memory, and the ability to acquire new memories. TABLE 39.1 Comparison of the Two Major Types of Dementia: Alzheimer’s Disease and Vascular Dementia Alzheimer’s Disease Vascular Dementia Cause Genetic and environmental factors; possibly viral Strokes or other vascular disorders that decrease blood flow to the brain Pathophysiologic changes Chronic, terminal disease that is characterized by formation of neuritic plaques, neurofibrillary tangles, and vascular degeneration in the brain Impaired blood flow to the brain, causing ischemia or necrosis of brain neurons Course of dementia Steady and gradual decline of cognitive, mobility, and ADL function from mild through severe stages; patients usually die from complications of immobility Stepwise progression of dementia symptoms that get significantly worse after each vascular event, such as a stroke or series of ministrokes; symptoms may improve as collateral circulation to vital neurons develops Risk factors Female Over 65 years of age Down syndrome Traumatic brain injury Male Over 65 years of age History of diabetes mellitus (DM), high cholesterol, myocardial infarction, atherosclerosis, hypertension, smoking, obesity Management Safety measures to prevent injury, wandering, or falls Cholinesterase inhibitors Behavior management ADL and mobility assistance as needed based on stage Identification of risk factors and management of the risk for or actual vascular event (e.g., antidiabetes drugs for DM, antihypertensive drugs, low-fat diet, smoking cessation, weight loss) Safety measures to prevent injury or falls Behavior management Etiology and Genetic Risk. The exact cause of AD is unknown. It is well established that age, gender, and genetics are the most important risk factors. Age is strongly linked to the incidence of AD for people older than 65, and women are more likely to develop the disease than men (McCance et al., 2019). As older adults age further, they become more at risk for the disease. Although not commonly occurring, when AD is diagnosed in people in their 40s and 50s, it is referred to as early dementia, Alzheimer’s type, or presenile dementia. Other risk factors for AD have been studied, including chemical imbalances, environmental agents, immunologic changes, excessive stress, and ethnicity/race. There is also a high incidence of AD in people who have Down syndrome (Alzheimer’s Association, 2018). Patient-Centered Care: Veterans Health Considerations Veterans who have experienced a traumatic brain injury (TBI) or repeated head trauma causing chronic traumatic encephalopathy (CTE) are more at risk for AD and at an earlier age than others. Those who have a diagnosis of posttraumatic stress disorder (PTSD) are twice as likely to develop dementia than veterans without PTSD. Rural veterans have an increased risk of dementia from PTSD and often have difficulty accessing Veterans Affairs (VA) and other support services. To add to this problem, health professionals working in rural areas may lack the specialized knowledge in how to care for these patients (Tasseff & Nies, 2017). Patient-Centered Care: Genetic/Genomic Considerations There is little doubt that many patients with AD had a genetic predisposition to the development of the disease. The most well-established genetic factor for AD in Euro-Americans is apolipoprotein E (APOE), a protein that transports cholesterol. Individuals who have one or more of the e4 forms of the protein are at high risk for AD; however, they may not actually develop the disease (Alzheimer’s Association, 2018). Patient-Centered Care: Cultural/Spiritual Considerations African Americans and Hispanics have a greater risk for developing AD when compared with non-Hispanic whites (Euro-Americans) (Alzheimer’s Association, 2018). The exact reason for these differences is not known, but factors that may influence these differences include increased body mass index (obesity), smoking, and depression, which occur more commonly in minority groups when compared with non-Hispanic whites. Incidence and Prevalence. There is a significant increase in both the incidence and prevalence of AD after 65 years of age, although it may affect anyone older than 40 years. The number of people in the United States with AD is estimated at over 5.7 million. One in 10 people in the United States over 65 years of age has the disease. Eight-one percent are over 75 years of age (Alzheimer’s Association, 2018). AD has a significant impact on health care costs, including direct (such as drug therapy and primary health care provider visits) and indirect medical costs (such as home care or nursing home care). Millions of informal caregivers, most often spouses/partners or other family members, provide care at home for years for most patients with AD. Many of these individuals are at risk for physical and psychosocial problems as a result of the burden of caregiving. Health Promotion and Maintenance. There are no proven ways to prevent AD; however, research is ongoing. Many patients with AD have other chronic health problems, such as diabetes mellitus, strokes, and atherosclerosis. Maintaining a healthy lifestyle helps to prevent these problems, such as eating a well-balanced diet, and consuming sufficient amounts of nutrients. Walking, swimming, and other exercise not only increase tone and muscle strength but also may decrease cognitive decline. Potentially harmful lifestyle habits that increase the individual’s risk of stroke and cardiovascular disease should be avoided, such as smoking and excessive alcohol intake. Interprofessional Collaborative Care Assessment: Recognize Cues History A thorough history and physical assessment are necessary to differentiate AD from other, possibly reversible causes of impaired cognition. Some patients experience cognitive impairment as acute confusion (delirium) as discussed in Chapter 4. Table 3.1 in Chapter 3 compares dementia and delirium. Patients who have dementia are at an increased risk of delirium when hospitalized or admitted to a long-term care (LTC) setting. Obtain information from family members or significant others because the patient may be unaware of the problems, denying their existence or covering them up. Some family members often do not recognize or may deny early changes in their loved one as well. Others may recognize subtle changes early in the disease process. The most important information to be obtained is the onset, duration, progression, and course of the symptoms. Question the patient and the family about changes in memory or increasing forgetfulness and about the ability to perform ADLs. Ask about current employment status; work history; military history; and ability to fulfill household responsibilities, including cleaning, grocery shopping, and preparing meals. Inquire about changes in driving ability, ability to handle routine financial transactions, and language and communication skills. In addition, document any changes in personality and behavior. Assessing functional status for complex chronic conditions such as dementia is a recommended core measure by the Centers for Medicare and Medicaid Services. Physical Assessment/Signs and Symptoms Stages of Alzheimer’s Disease The National Institute of Aging in the United States recognizes three phases of AD: Asymptomatic preclinical phase Symptomatic predementia phase (mild impaired cognition ) Dementia phase The signs and symptoms associated with the dementia phase can be grouped into three broad stages based on the progress of the disease, as outlined in the Key Features: Alzheimer’s Disease box. Key Features Alzheimer’s Disease Early (Mild), or Stage I (First Symptoms up to 4 Years) Independent in ADLs Denies presence of symptoms Forgets names; misplaces household items Has short-term memory loss and difficulty recalling new information Shows subtle changes in personality and behavior Loses initiative and is less engaged in social relationships Has mild impaired cognition and problems with judgment Demonstrates decreased performance, especially when stressed Unable to travel alone to new destinations Often has decreased sense of smell Middle (Moderate), or Stage II (2 to 3 Years) Has impairment of all cognitive functions Demonstrates problems with handling or unable to handle money and finances Is disoriented to time, place, and event Is possibly depressed and/or agitated Is increasingly dependent in ADLs Has visuospatial deficits: has difficulty driving and gets lost Has speech and language deficits: less talkative, decreased use of vocabulary, increasingly nonfluent, and eventually aphasic  Incontinent Psychotic behaviors, such as delusions, hallucinations, and paranoia Has episodes of wandering; trouble sleeping Late (Severe), or Stage III Completely incapacitated; bedridden Totally dependent in ADLs Has loss of mobility and verbal skills Possibly has seizures and tremors Has agnosia The patient does not necessarily progress from one stage to the next in an orderly fashion. A stage may be bypassed, or he or she may exhibit symptoms of one or several stages. Each patient exhibits different disease stages and signs and symptoms. Consequently, most authorities now use broader terms such as early (mild), middle (moderate), and late (severe) stages, although other staging systems exist. Changes in Cognition As defined in Chapter 3, cognition is the complex integration of mental processes and intellectual function for the purposes of reasoning, learning, and memory. Therefore assess patient for deficits in these abilities: Attention and concentration Judgment and perception Learning and memory Communication and language Speed of information processing One of the first symptoms of AD is short-term memory impairment. New memory and defects in information retrieval result from dysfunction in the hippocampal, frontal, or parietal region. Alterations in communication abilities, such as apraxia (inability to use words or objects correctly), aphasia (inability to speak or understand), anomia (inability to find words), and agnosia (loss of sensory comprehension, including facial recognition), are due to dysfunction of the temporal and parietal lobes. Frontal lobe impairment causes problems with judgment, an inability to make decisions, decreased attention span, and a decreased ability to concentrate. As the disease progresses to a later stage, the patient loses all cognitive abilities, is totally unable to communicate, and becomes less aware of the environment. To more clearly identify the nature and extent of the patient’s impaired cognition, the neurologist or psychologist administers several neuropsychological tests. The tests selected depend on clinician preference and the ability of the patient to participate in testing. All of the tests focus on cognitive ability and may be repeated over time to measure changes. Folstein’s Mini-Mental State Examination (MMSE) is an example of a tool used to determine the onset and severity of cognitive impairment. The MMSE is also known as the “mini-mental exam.” The MMSE assesses five major areas—orientation, registration, attention and calculation, recall, and speech-language (including reading). The patient performs certain cognitive tasks that are scored and added together for a total score of 0 to 30. The lower the score is, the greater the severity of the dementia. It is not unusual for a patient with advanced AD to score below 5. Another sensitive tool used by health professionals to screen for dementia is the Montreal Cognitive Assessment Test (MoCA). Although the MMSE and MoCA are used frequently, they require that the patient be able to read. For the patient who cannot read or for a quicker screening test, the “set test” can be used. The patient is asked to name 10 items in each of four sets or categories: fruits, animals, colors, and towns (FACT). Other categories can be used, if needed. The patient receives 1 point for each item for a possible maximum score of 40. Patients who score above 25 do not have dementia. Although this assessment is easy to administer, it should not be used for patients with hearing impairments or speech and language problems. The Clock Drawing Test does not require that the patient can read and is nonthreatening to perform. In LTC settings, the federally required Brief Interview for Mental Status (BIMS) is included as part of the Minimum Data Set 3.0 for Nursing Homes (see Chapter 4). Changes in Behavior and Personality One of the most difficult aspects of AD and other types of dementia with which families and caregivers cope is the behavioral changes that can occur in advanced disease. Assess the patient for: Aggressiveness, especially verbal and physical abusive tendencies Rapid mood swings Increased confusion at night or when light is not adequate (“sundowning”) or in excessively fatigued patients The patient may wander and become lost or may go into other rooms to rummage through another’s belongings. Hoarding or hiding objects is also common. For example, patients may hoard washcloths in the long-term care setting. For some patients with dementia, emotional and behavioral problems occur with the primary disease. They may experience paranoia (suspicious behaviors), delusions, hallucinations, and depression. Document these behaviors and ensure the patient’s safety. (Refer to a mental health/behavior health nursing textbook for a complete discussion of these psychotic disorders.) Changes in Self-Management Skills Observe for changes in the patient’s self-management skills that decline over time, such as: Decreased interest in personal appearance Selection of clothing that is inappropriate for the weather or event Loss of bowel and bladder control Decreased appetite or ability to eat (often due to forgetting how to chew food and swallow in late dementia) Over time, the patient becomes less mobile, and complications of impaired mobility develop. These potential complications are listed in Table 3.3 in Chapter 3 of this textbook. The patient eventually becomes totally immobile and requires total physical care. Psychosocial Assessment In people with dementia, the cognitive changes and biochemical and structural dysfunctions affect personality and behavior. In the early stage, patients often recognize that they are experiencing memory or cognitive changes and may attempt to hide the problems. They begin the grieving process because of anticipated loss, experiencing denial, anger, bargaining, and depression at varying times. When the patient and family receive the diagnosis, one or more family members may desire genetic testing. Support the patient’s/family’s decisions regarding testing and help them find credible resources for testing and professional genetics counseling. As the disease progresses, patients begin to display major changes in emotional and behavioral affect. Of particular importance is the need for an assessment of the patients’ reactions to changes in routine or environment. For example, a hospital admission is very traumatic for most patients with dementia. It is not unusual for them to exhibit a catastrophic response or overreact to any change by becoming excessively aggressive or abusive. This is referred to as traumatic relocation syndrome. Sexual disinhibition is one of the most challenging symptoms for both family and staff members. Sexually inappropriate behaviors may include masturbating publicly, attempting sexual acts on staff or other patients, disrobing or exposing the genital area, and/or making sexualized comments to staff or other patients. Assess a history of or current manifestation of these behaviors to include into the patient’s plan of care. Neuropsychiatric symptoms are common in patients with AD and increase as the disease progresses and aphasia increases. The patient’s emotions are often displayed as nonverbal behaviors, including hitting, yelling, and agitation. Any new hospital procedure may cause anxiety and fear as a trigger for these behaviors. As patients become unaware of their behavior, the focus of the psychosocial assessment shifts to the family or significant others. The interprofessional health care team assesses their ability to cope with the chronicity and progression of the disease and identifies possible support systems. Laboratory and Imaging Assessment No laboratory test can confirm the diagnosis of AD. Definitive diagnosis is made on the basis of brain tissue examination at autopsy, which confirms the presence of neurofibrillary tangles and neuritic plaques. Genetic testing, specifically for apolipoprotein E4 (APOE 4), may be helpful as an ancillary test (not a predictive test) for the differential diagnosis of AD. Amyloid beta protein precursor (soluble) (sBPP) may be measured for patients to diagnose AD and other types of dementia. A decrease in the patient’s sBPP in the cerebrospinal fluid (CSF) supports the diagnosis because the amyloid tends to deposit in the brain and is not circulating in the CSF (Pagana & Pagana, 2018). A variety of imaging tests (CT or MRI) may be performed to rule out other treatable causes of dementia or delirium. The CT scan typically shows cerebral atrophy, vascular degeneration, ventricular enlargement, wide sulci, and shrunken gyri in the later stages of the disease. NCLEX Examination Challenge 39.1 Psychosocial Integrity The nurse assesses a client with a diagnosis of early-stage Alzheimer’s disease. Which assessment findings would the nurse expect for this client? Select all that apply. A. Forgetfulness B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating F. Personality changes Analysis: Analyze Cues and Prioritize Hypotheses. The priority collaborative problems for patients with Alzheimer’s disease (AD) include: 1. Decreased memory and cognition due to neuronal changes in the brain 2. Potential for injury or falls due to wandering or inability to ambulate independently 3. Potential for elder abuse by caregivers due to the patient’s prolonged progression of disability and the patient’s increasing care needs Planning and Implementation: Generate Solutions and Take Action. The priority for interprofessional care is safety! Chronic confusion and physical deficits place the patient with AD at a high risk for injury, accidents, and elder abuse. Managing Memory and Cognitive Dysfunction Planning: Expected Outcomes In the very early stages of the disease, the patient with AD is expected to maintain the ability to perform basic mental processes. As the disease progresses, patients cannot meet this outcome. Instead, the desired outcome is to maintain memory and cognition for as long as possible to keep patients safe and increase their quality of life. Interventions Although drug therapy may be used for patients with AD, nonpharmacologic interventions are the main focus of nursing teamwork and interprofessional collaboration. Teach family members and significant others about the importance of being consistent in following the individualized plan of care. Nonpharmacologic Management Behavioral management in a structured environment. The primary health care provider should answer the patient’s questions truthfully concerning the diagnosis of AD. In this way, the patient and family can more fully participate in the interprofessional plan of care. Interventions are the same whether he or she is cared for at home, in an adult day-care center, in an assisted-living center, in an LTC facility, or in a hospital. The patient with memory problems benefits best from a structured and consistent environment. Training in communication can help nurses and health care team members interact with better affect and compassion. Many factors, including physical illness and environmental factors, can exacerbate (worsen) the signs and symptoms of AD. The patient with dementia frequently has other health problems such as cardiovascular disease, arthritis, renal insufficiency, and pulmonary disease. Changes in vision and hearing also may be present. Managing these problems often improves the patient’s functional ability. Approaches to managing the patient who has AD include: Cognitive stimulation and memory training Structuring the environment Orientation or validation therapy Promoting self-management Promoting bowel and bladder continence Promoting communication The purpose of cognitive stimulation and memory training is to reinforce or promote desirable cognitive function and facilitate memory. Cognitive-stimulation therapy programs and mindfulness provide some benefit for patients. An example of cognitive stimulation is to show a video of family members to the patient with dementia to manage behaviors or help improve memory. Interactive animal-assisted therapy can help patients with mild-to-moderate impaired cognition to decrease disruptive or psychotic behaviors (see the Evidence-Based Practice box). Evidence-Based Practice Does Animal-Assisted Therapy Help Patients With Dementia? Yakimicki, M. L., Edwards, N. E., Richards, E., & Beck, A. M. (2018). Animal-assisted intervention and dementia: A systematic review. Clinical Nursing Research, 28(1), 9−29. The authors conducted a systematic review of the literature to determine the effectiveness, if any, of animal-assisted therapy as an intervention for patients with dementia. After a complete appraisal, 32 studies were selected for review. As a result of pet therapy, findings included: 27 of the 32 studies used dogs as an intervention. 9 of 15 studies demonstrated an improvement in agitation and aggression. 11 of 12 studies showed that patients had increased social interaction. 3 of 4 studies revealed an improved quality of life. All of the studies showed that patients with dementia increased their social and physical activities. Level of Evidence: 1 The research was a systematic review of the literature that included multiple studies to summarize best practices for a specific intervention for patients with dementia. Implications for Nursing Practice and Research: This research provides evidence for using animal-assisted interventions to help patients with dementia manage behaviors and improve social and physical activity. Nurses need to explore how this intervention can be used in both health care and community settings. Although this research did not limit its search to studies of patients with Alzheimer’s disease, all patients with dementia, regardless of type, may exhibit disruptive behaviors and socially withdraw. Additional systematic reviews for other interventions need to be conducted as the population ages and the incidence of dementia is expected to increase. As the disease progresses, the patient may experience an inability to recognize oneself and other familiar faces. Encourage the family to provide pictures of family members and close friends that are labeled with the person’s name on the picture. In addition, advise the family to reminisce with the patient about pleasant experiences from the past. Use reminiscence therapy while assisting the patient with ADLs or performing a treatment or assessment. Refer to personal items in the room to help the patient begin to talk about its meaning in the present and in the past. It is not unusual for the patient to talk to his or her image in the mirror. This behavior should be allowed as long as it is not harmful. If the patient becomes frightened by the mirror image, remove or cover the mirror. In some long-term care or memory-care units, a picture of the patient is placed on the room door to help with facial recognition and to help the patient locate his or her room. This picture also helps the staff locate the patient in case of wandering or elopement. Teach the family to keep environmental distractions and noise to a minimum. The patient’s home, hospital room, or nursing home room should not have pictures on the wall or other decorations that could be misinterpreted as people or animals that could harm the patient. An abstract painting or wallpaper might look like a fire or an explosion and scare the patient. The room should have adequate, nonglare lighting and no potentially frightening shadows. In addition to disturbed sleep, other negative effects of high noise levels include decreased nutritional intake, changes in blood pressure and pulse rates, and feelings of increased stress and anxiety. The patient with AD is especially susceptible to these changes and needs to have as much undisturbed sleep at night as possible. Fatigue increases confusion and behavioral manifestations such as agitation and aggressiveness. Nursing Safety Priority Action Alert When a patient with Alzheimer’s disease is in a new setting or environment, collaborate with the staff and admitting department to select a room that is in the quietest area of the unit and away from obvious exits, if possible. A private room may be needed if the patient has a history of agitation or wandering. The television should remain off unless the patient turns it on or requests that it be turned on. Objects such as furniture, a hairbrush, and eyeglasses should be kept in the same place. Establish a daily routine and follow it as much as possible. Arrange for a communication board or digital handheld device for scheduled activities and other information to promote orientation such as the day of the week, the month, and the year. Pictures of people familiar to the patient can also be placed on this board. Explain changes in routine to the patient before they occur, repeating the explanation immediately before the changes take place. Clocks and single-date calendars also help the patient maintain day-to-day orientation to the environment in the early stages of the disease process. For the patient with early disease, reality orientation is usually appropriate. Teach family members and health care staff to frequently reorient the patient to the environment. Remind the patient what day and time it is, where he or she is, and who you are. For the patient in the later stages of AD or dementia, reality orientation does not work and often increases agitation. The interprofessional health care team uses validation therapy for the patient with moderate or severe AD. In validation therapy, the staff member recognizes and acknowledges the patient’s feelings and concerns. For example, if the patient is looking for his or her mother, ask him or her to talk about what Mother looks like and what she might be wearing. This response does not argue with the patient but also does not reinforce the patient’s belief that Mother is still living. As the disease progresses, altered thought processes affect the ability to perform ADLs. Encourage the patient to perform as much self-care as possible and to maintain independence in daily living skills as long as possible. For example, in the home setting, complete clothing outfits that can be easily placed on a single hanger are preferred for patient selection. When possible, the patient should participate in meal preparation, grocery shopping, and other household routines. NCLEX Examination Challenge 39.2 Psychosocial Integrity A client with moderate dementia asks the nurse to find her son who is deceased. What is the nurse’s most appropriate response? A. “We can call him in a little while if you want.” B. “Your son died over 20 years ago.” C. “What did your son look like?” D. “I’ll ask your husband to find him when he visits.” Interprofessional Collaboration Care of Patients with Alzheimer’s Disease Collaborate with the occupational and physical therapists to provide a complete evaluation and assistance in helping the patient remain as independent as possible. Adaptive devices, such as grab bars in the bathtub or shower area, an elevated commode, and adaptive eating utensils, may enable him or her to maintain independence in grooming, toileting, and feeding. The physical therapist prescribes an exercise program to improve physical health and functionality. According to the Interprofessional Education Collaborative (IPEC) Expert Panel’s Competency of Roles and Responsibilities, using the unique and complementary abilities of other team members optimizes health and patient care (IPEC, 2016; Slusser et al., 2019). The patient may remain continent of bowel and bladder for long periods if taken to the bathroom or given a bedpan or urinal every 2 hours. Toileting may be needed more often during the day and less frequently at night. Assistive personnel (AP) or home caregivers should encourage the patient to drink adequate fluids to promote optimal voiding. A patient may refuse to drink enough fluids because of a fear of incontinence. Assure the patient that he or she will be toileted on a regular schedule to prevent incontinent episodes. When patients with dementia are in the hospital or another unfamiliar place, avoid the use of restraints, including side rails. Serious injury can occur when a patient with dementia attempts to get out of bed with either limb restraints or side rail use. Use frequent surveillance, toileting every 2 hours, and other strategies to prevent falls. In some cases, sitters may be used to help prevent patient injury. Chapter 4 discusses fall prevention in detail. Maintain a clear path between the bed and bathroom at all times. For patients who are too weak to walk to the bathroom, a bedside commode may be used. Some patients may void in unusual places, such as the sink or a wastebasket. As a reminder of where they should toilet, place a picture of the commode on the bathroom door. Complementary and integrative health. If culturally appropriate and if the patient allows being touched by staff, teach AP to provide a massage before bedtime to promote sleep or at other times to reduce stress and promote relaxation. Use some type of oil or lotion if the patient does not have allergies to these substances. Slow, rhythmic massage strokes on the upper back, neck, and shoulders can be very relaxing and calming (Westman & Blaisdell, 2016). Essential oils such as lavender and bergamot may also produce a calming effect and promote relaxation (Allard & Katseres, 2016). Use redirection by attracting the patient’s attention to promote communication. Keep the environment as free from distractions as possible. Speak directly to the patient in a distinct manner. Sentences should be clear and short. Remind the patient to perform one task at a time and allow sufficient time for completion. It may be necessary to break each task down into many small steps and limit choices. The Best Practice for Patient Safety & Quality Care: Promoting Communication With the Patient With Alzheimer’s Disease box lists other tips for communicating with patients who have AD. As the disease progresses, the patient is unable to perform tasks when asked. Show the patient what needs to be done, or provide cues to remind him or her how to perform the task. When possible, explain and demonstrate the task that the patient is asked to perform. Best Practice for Patient Safety & Quality Care Promoting Communication With the Patient With Alzheimer’s Disease Ask simple, direct questions that require only a “yes” or “no” answer if the patient can communicate. Provide instructions with pictures in a place that the patient will see if he or she can read them. Use simple, short sentences and one-step instructions. Use gestures to help the patient understand what is being said. Validate the patient’s feelings as needed. Limit choices; too many choices cause frustration and increased confusion. Never assume that the patient is totally confused and cannot understand what is being communicated. Try to anticipate the patient’s needs and interpret nonverbal communication. Patients with dementia disorders typically have specific speech and language problems. Recognize that emotional and physical behaviors may be a form of communication. Interpret the meaning of these behaviors to address them. For example, restlessness may indicate urinary retention, pain, infection, or hypoxia (lack of oxygen to the brain). Collaborate with the speech-language pathologist to assist with communication ability. Drug Therapy There are no drugs that can cure or slow the progression of Alzheimer’s disease, but a few drugs may improve symptoms associated with the disease for some patients. Psychotropic drugs may be prescribed to help control the signs and symptoms of associated mental/behavioral health problems (e.g., depression, anxiety, paranoia). Cholinesterase inhibitors are drugs approved for treating AD symptoms. They work to improve cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine (ACh) by the enzyme cholinesterase. This action may slow the onset of cognitive decline in some patients, but none of these drugs alters the course of the disease. In some cases, cholinesterase inhibitors can improve functional ADL ability. Examples include donepezil, galantamine, and rivastigmine (Burchum & Rosenthal, 2019). Nursing Safety Priority Drug Alert Teach the family to monitor the patient’s heart rate and report dizziness or falls because cholinesterase inhibitors can cause bradycardia. Therefore they are used cautiously for patients who have a history of heart disease. Memantine is the first of a new class of drugs that is a low-to-moderate affinity N -methyl-d-aspartate (NMDA) receptor antagonist. Overexcitation of NMDA receptors by the neurotransmitter glutamate may play a role in AD. This drug blocks excess amounts of glutamate that can damage nerve cells. It is indicated for advanced AD and has been shown in some patients to slow the pace of deterioration (Burchum & Rosenthal, 2019). Memantine may help maintain patient function for a few months longer. Some patients also have improved memory and thinking skills. This drug can be given with donepezil, a cholinesterase inhibitor. Some patients with AD develop depression and may be treated with antidepressants. Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine and sertraline, are typically prescribed. Psychotropic drugs, also called antipsychotic or neuroleptic drugs, should be reserved for patients with psychoses that sometimes accompany dementia, such as hallucinations and delusions. However, in clinical practice, these drugs are sometimes incorrectly used for agitation, combativeness, or restlessness. Psychotropic drugs are considered chemical restraints because they decrease mobility and patients’ self-management ability. Therefore most geriatricians recommend that they be used as a last resort and with caution in low doses for a specific mental/behavioral health problem. The specific drug prescribed depends on side effects, the condition of the patient, and expected outcomes. Follow agency policy and The Joint Commission standards concerning the use of chemical restraints. Best Practice for Patient Safety & Quality Care Approaches to Prevent and Manage Wandering in Hospitalized Patients  Identify the patients most at risk for wandering through observation and history provided by family. Provide appropriate supervision, including frequent checks (especially at shift-change times). Place the patient in an area that provides maximum observation but not in the nurses’ station. Use family members, friends, volunteers, and sitters as needed to monitor the patient. Keep the patient away from stairs or elevators. Do not change rooms to prevent increasing confusion. Avoid physical or chemical restraints. Assess and treat pain. Use reorientation methods or validation therapy, as appropriate. Provide frequent toileting and incontinence care as needed. Use bed and/or chair alarms, as available. If possible, prevent overstimulation, such as excessive noise. Use soft music and nonglare lighting if possible. Preventing Injuries or Falls Planning: Expected Outcomes The patient with dementia is expected to remain free from physical harm and not injure anyone else. Interventions Many patients with dementia tend to wander and may easily become lost. In later stages of the disease, some patients may become severely agitated and physically or verbally abusive to others. Teach the family the importance of a patient identification badge or bracelet. The badge should include how to contact the primary caregiver. In an inpatient setting, check the patient frequently and place him or her in a room that can be monitored easily. The room should be away from exits and stairs. Some health care agencies place large stop signs or red tape on the floor in front of exits. Others have installed alarm systems to indicate when a patient is opening the door or getting out of a bed or chair. Restlessness may be decreased if the patient is taken for frequent walks. If the patient begins to wander, redirect him or her. For example, if the patient insists on going shopping for clothes, he or she is redirected to his or her closet to select clothing that will not be recognized as his or her own. This type of activity can be repeated a number of times because the patient has lost short-term memory. Interventions for preventing and managing wandering are listed in the Best Practice for Patient Safety & Quality Care: Approaches to Prevent and Manage Wandering in Hospitalized Patients box. In any setting, keep the patient busy with structured activities. In a health care agency, an activity therapist or volunteer may work with patients as a group or individually to determine the type of activity that is appropriate for the stage of the disease. Puzzles, board games, art supplies, and computer games are often appropriate. Music and art therapy are also helpful activities to keep patients with AD busy while stimulating cognition. These activities allow patients to be engaged and promote their creativity. Nursing Safety Priority Action Alert In inpatient health care agencies, use the least restrictive physical restraints, such as waist belts and geri-chairs with lapboards, only as a last resort because they often increase patient restlessness and cause agitation. Federal regulations in long-term care facilities in the United States mandate that all residents have the right to be free of both physical and chemical restraints. All health care agencies accredited by The Joint Commission are required to use alternatives to restraints before resorting to any physical or chemical restraint. Patients with dementia may be injured because they cannot recognize objects or situations as harmful. Remove or secure all potentially dangerous objects (e.g., knives, drugs, cleaning solutions). Patients are often unaware that their driving ability is impaired and usually want to continue this activity even if their driver’s license has been suspended or they are unsafe. Automobile keys must be secured, but the patient should be told why they were taken. (See Chapter 4 for more discussion on older-adult driving.) Late in the disease process, the patient may experience seizure activity. If he or she is cared for at home, teach caregivers what action to take when a seizure occurs to prevent injury. (See the discussion of Interventions in the Seizures and Epilepsy section.) Talking calmly and softly and attempting to redirect the patient to a more positive behavior or activity are effective strategies when he or she is agitated. For example, some patients refuse to take a bath or are unable to bathe. Bathing disability predicts decline for patients with dementia and, combined with safety issues, often leads the family to place them in long-term care (LTC) settings. LTC staff may label these patients as “difficult” when they aggressively refuse to bathe. Use calm, positive statements and reassure the patient that he or she is safe. Statements such as, “I’m sorry that you are upset,” “I know it’s hard,” and “I will have someone stay with you until you feel better” may help. Actions to avoid when the patient is agitated include raising the voice, confronting, arguing, reasoning, taking offense, or explaining. Teach the caregiver to not show alarm or make sudden movements out of the person’s view. If the patient remains agitated, ensure his or her safety and leave the room after explaining that you will return later. Frequent visual checks must be done during this time. If the patient is connected to any type of tubing or other device, he or she may try to disconnect it or pull it out. These devices should be used cautiously in the patient with dementia. For example, if IV access is needed, the catheter or cannula is placed in an area that the patient cannot easily see, or it should be covered. Another way to manage this problem is to provide a diversion. For example, if the patient is doing an activity or holding an item such as a stuffed animal or other special item, he or she might be less likely to pay attention to medical devices. Additional strategies to minimize behavioral problems, especially at home, are listed in Table 39.2. Patients who are cared for at home are at high risk for neglect or abuse. The Joint Commission requires all patients to be assessed for neglect and abuse on admission to a health care facility. Patients with mild dementia may not report these concerns for fear of retaliation. Those with severe dementia may not have the ability to report the abuse. Asking questions such as, “Who cooks for you?” “Do you get help when you need it?” or “Do you wait long for help to the bathroom?” may be less stressful for the patient to answer. TABLE 39.2 Minimizing Behavioral Problems for Patients With Alzheimer’s Disease at Home Carefully evaluate the patient’s environment to ensure it is safe: Remove small area rugs. Consider replacing tile floors with nonslippery floors. Arrange furniture and room decorations to maximize the patient’s safety when walking. Minimize clutter in all rooms in and outside of the house. Install nightlights in patient’s room, bathroom, and hallway. Install and maintain smoke alarms, fire alarms, and natural gas detectors. Install safety devices in the bathroom such as handles for changing position (sit-to-stand). Install alarm system or bells on outside doors; place safety locks on doors and gates. Ensure that door locks cannot be easily opened by the patient. Help the patient with mild-stage disease remain oriented to the extent possible: Place single-date calendars in patient’s room and in kitchen.  Use large-face clocks with a neutral background. Communicate with the patient based on his or her ability to understand: Explain activity immediately before the patient needs to carry it out. Break complex tasks down to simple steps. Allow and encourage the patient to be as independent as possible in ADLs: Place complete outfits for the day on hangers; have the patient select one to wear. Develop and maintain a predictable routine (e.g., meals, bedtime, morning routine). When a problem behavior occurs, divert patient to another activity; minimize excessive stimulation: Take the patient on outings when crowds are small. If crowds cannot be avoided, minimize the amount of time the patient is present in a crowd. For example, at family gatherings, provide a quiet room for the patient to rest throughout the visit. Arrange for a day-care program to maintain interaction and provide respite for home caregiver. In the United States (www.alz.org); in Canada, register the patient with the Alzheimer Society of Canada Medic Alert Safely Home program (www.alzheimer.ca). Preventing Elder Abuse Planning: Expected Outcomes The family or other caregivers of the patient with dementia are expected to plan time to care for themselves to promote a reasonable quality of life and satisfaction, which should help prevent patient abuse. Interventions AD is a chronic, progressive condition that eventually leaves the patient completely dependent on others for all aspects of care. The patient with moderate or severe dementia requires continual 24-hour supervision and caregiving. Severe cognitive changes leave the patient unable to manage finances, property, or personal care. The family needs to seek legal counsel regarding the patient’s competency and the need to obtain guardianship or a durable medical power of attorney when necessary. Millions of family caregivers provide direct care for patients with impaired cognition. Family caregivers include relatives, significant others, and neighbors who provide the majority of home health care. A qualitative study by Czekanski (2017) examined the experience of transitioning of family members, usually spouses and daughters, to the role of caregiver for patients with AD or related dementias. As a result of the study, the researcher identified common themes experienced by family caregivers, which included losses and challenges, seeking knowledge and support, and preserving themselves without guilt. Teach family caregivers to be aware of their own health and stress levels. Signs of stress include anger, social withdrawal, anxiety, depression, lack of concentration, sleepiness, irritability, and physical health problems. When signs of stress and strain occur, the caregiver should be referred to his or her primary health care provider or seek one on his or her own. It is not unusual for the caregiver to refuse to accept help from others, even for a few brief hours. Initially, the caregiver may be more comfortable accepting help for just a few minutes a day so that he or she could shower, enjoy a cup of tea, or take a brief walk. Some caregivers find that eventually they need to place their loved one into a respite setting or unit so they can re-energize and prevent or manage spiritual distress. Patient-Centered Care: Cultural/Spiritual Considerations Both religion and spirituality can help family caregivers give meaning to the work they provide for patients with AD. Spirituality is considered an important part of holistic patient care; it may or may not include religion. Spirituality and religion may decrease the incidence of caregiver depression and anxiety. Assess the patient’s and family caregiver’s cultural beliefs and values related to spirituality and religion. The Patient and Family Education: Preparing for Self-Management: Reducing Family/Informal Caregiver Stress box lists strategies for reducing caregiver stress and includes interventions to promote spirituality and prevent spiritual distress. Patient and Family Education: Preparing for Self-Management Reducing Family/Informal Caregiver Stress Maintain realistic expectations for the person with Alzheimer’s disease (AD). Take each day one at a time. Try to find the positive aspects of each incident or situation. Use humor with the person who has AD. Use the resources of the Alzheimer’s Association in the United States (or Alzheimer Society of Canada), including attending local support group meetings and using the AD toll-free hotline when needed. Explore alternative care settings early in the disease process for possible use later. Establish advance directives with the AD patient early in the disease process. Set aside time each day for rest or recreation away from the patient, if possible. Seek respite care periodically for longer periods of time. Take care of yourself by watching your diet, exercising, and getting plenty of rest. Be realistic about what you or they can do and accept help from family, friends, and community resources. Use relaxation techniques, including meditation and massage. Seek out clergy or other spiritual counselor as needed. As stated earlier, African Americans and Hispanics have a greater risk for developing AD and often earlier and typically live longer than non-Hispanic whites (Euro-Americans). These ethnic groups are known to be very family centered and tend to care for their family members at home as needed. As a result of these values and beliefs, an increase in family caregivers is expected as the number of older ethnic minority adults increases dramatically within the next 20 to 30 years. More research that focuses on older adults from these populations is needed to better provide essential care and support. Care Coordination and Transition Management Home Care Management In the early stages of AD, patients may be cared for at home with little need for outside intervention. Whenever possible, the patient and family should be assigned a case manager who can assess their needs for health care resources and find the best placement throughout the continuum of care. The patient usually begins to withdraw from friends and social events as memory impairment and personality and behavior changes progress. The family may begin to decrease their own social activities as the demands of the patient’s care take more of their time. Emphasize to the family the importance of maintaining their own social contacts and leisure activities. In most areas of the United States and Canada, respite care is available for families. The patient may be placed in a respite facility or nursing home for the weekend or for several weeks to give the family a rest from the constant care demands. The family may also be able to obtain respite care in the home through a home care agency or assisted-living facility. Remind the family that respite care is for a short period; it is not permanent placement. Some health care agencies have opened adult medical day-care centers or memory care units for patients with AD. In the day-care center, patients spend all or part of the day at the facility and participate in activities as their condition permits. Although these centers are usually open only on weekdays, this arrangement allows the caregiver to work or participate in other activities. If patients require 24-hour care, they may be placed in a memory-care unit of a long-term care or assisted-living facility. Teach the family how to be prepared in case the patient becomes restless, agitated, abusive, or combative. In addition, the family can learn how to use reality orientation or validation therapy, depending on the stage of the disease. Self-Management Education Usually patients with AD and dementia are cared for in the home until late in the disease process unless they can afford private-pay care. Because health insurance coverage in the United States and family finances may not be sufficient to cover the services of a private duty nurse or home care aide, family members typically provide the care. The patient plan of care developed by the nurse or case manager, in conjunction with the family, must be reasonable and realistic for the family to implement. Provide information to the family on what to do in the event of a seizure and how to protect the patient from injury. Instruct them to notify the primary health care provider if the seizure is prolonged or if the patient’s seizure pattern changes. Review with the family or other caregiver the name, time, and route of administration; the dosage; and the side effects of all drugs. Remind the family to check with the health care provider before using any over-the-counter drugs or herbs because they may interact with prescribed drug therapy. Emphasis is placed on the need for the patient to have an established exercise program to maintain mobility for as long as possible and to prevent complications of immobility. In collaboration with the family, the physical therapist (PT) may develop an individualized exercise program. The PT may continue to work with the patient at home until goals are achieved, depending on the payer source. Remind the family or other caregiver to take special precautions to maintain the patient safely at home. The environment must be uncluttered, consistent, and structured. All hazardous items (e.g., cooking range and oven, power tools) are removed, secured, or “locked out.” All electrical sockets not in use should be covered with safety plugs. Teach families to install handrails and grab bars in the bathroom. Handrails should be along all stairways, and a guardrail should be placed around porches or open stairwells. Because the patient may have a tendency to wander, especially at night, the family may want to install alarms to all outside doors, the basement, and the patient’s bedroom. All outside and basement doors should have deadbolt locks to prevent the patient from going outside unsupervised. Remind the family to adjust the temperature of the water to prevent accidental burns. Nightlights should be used in the patient’s bedroom, hallway, and bathroom to prevent fear and to help with orientation. Health Care Resources Refer all families to their local chapter of the Alzheimer’s Association (www.alz.org) in the United States or to the Alzheimer Society of Canada (www.alzheimer.ca). These organizations provide information and support services to patients and their families, including seminars, audiovisual aids, and publications. In most locations, caregiver telephone or email support is available. Teach the family to enroll the patient in the Safe Return Program, a U.S. government-funded program of the Alzheimer’s Association that assists in the identification and safe, timely return of people with dementia. The program includes registration of the patient and a 24-hour hotline to be called to assist in finding a lost patient. If a patient wanders and becomes lost, the family (or health care institution) should immediately notify the police department. An up-to-date picture of the patient makes it easier for local authorities, the public, and neighbors to identify the missing patient. Devices using radio-wave beacons and a global positioning system (GPS) have been developed to help families and law enforcement officials find a lost patient more easily. These devices include shoes with a GPS unit implanted, jewelry that is hard to remove, and bracelets. Caution families that these devices are not foolproof. Just like cell phones, there are some areas where the signal from the patient may not be picked up easily if at all. When the patient can no longer be cared for at home, referral to an assisted-living or long-term care facility may be needed. Early in the course of the disease, advise the family that placement might be needed in the late stages of the disease or sooner. This allows the family to begin to search for an appropriate facility before a crisis develops and immediate placement is needed. The national office of the Alzheimer’s Association publishes an outline of criteria for a memory-care unit. In the advanced stage of the disease, the patient may need referral to palliative and hospice services for total care. (See the discussion of end-of-life and hospice care in Chapter 8.) Patient-Centered Care: Veterans Health Considerations For veterans who have AD, help families locate the closest Veterans Administration (VA) for support and services. Services may include home-based primary care, homemaker and home health aides, respite care, adult day health care, outpatient clinics, inpatient hospital services, nursing home, or hospice care. Caregiver support is an essential part of all of these services. Evaluation: Evaluate Outcomes. Evaluate the care of the patient with AD based on the identified priority patient problems. The expected outcomes include that the patient and/or family will: Maintain memory and cognition for as long as possible and increase their quality of life Remain free from injury and accidents and have a safe environment Manage caregiver stress and strain to prevent elder abuse