Chapter 60: Nursing Management: Alzheimer’s Disease and Dementia

DEMENTIA
• Dementia is a syndrome characterized by dysfunction or loss of memory, orientation,
attention, language, judgment, and reasoning. Personality changes and behavioral problems
such as agitation, delusions, and hallucinations may result.

• The two most common causes of dementia are neurodegenerative conditions (e.g.,
Alzheimer’s disease) and vascular disorders. Vascular dementia, also called multiinfarct
dementia, is the loss of cognitive function resulting from ischemic, ischemic-hypoxic, or
hemorrhagic brain lesions caused by cardiovascular disease.

• Depending on the cause of the dementia, the onset of symptoms may be insidious and
gradual or more abrupt. Often dementia associated with neurologic degeneration is gradual
and progressive over time.

• Regardless of the cause of dementia, the initial symptoms are related to changes in cognitive
functioning. Patients may have complaints of memory loss, mild disorientation, and/or
trouble with words and numbers.

• An important first step in the diagnosis of dementia is a thorough medical, neurologic, and
psychologic history. Also, mental status testing is an important component of the patient
evaluation.

• Depression is often mistaken for dementia in older adults, and, conversely, dementia for
depression.

MILD COGNITIVE IMPAIRMENT

• Mild cognitive impairment (MCI) is a state of cognitive functioning that is below defined
norms, yet does not meet the criteria for dementia.

• Causes of MCI may include stress, anxiety, depression, or physical illness.

• The nurse caring for the patient with MCI must recognize the importance of monitoring the
patient for changes in memory and thinking skills that would indicate a worsening of
symptoms or a progression to dementia.

ALZHEIMER’S DISEASE
• Alzheimer’s disease (AD) is a chronic, progressive, degenerative disease of the brain. It is
the most common form of dementia.

• The exact etiology of AD is unknown. Similar to other forms of dementia, age is the most
important risk factor for developing AD.

• Characteristic findings of AD relate to changes in the brain’s structure and function: (1)
amyloid plaques, (2) neurofibrillary tangles, and (3) loss of connections between cells and
cell death.

• Multiple genetic factors have been linked to the development of AD. Inflammation is also
believed to contribute to AD.
• The manifestations of AD can be categorized similar to those for dementia as mild,
moderate, and late.

• An initial sign of AD is a subtle deterioration in memory. With progression of AD,

additional cognitive impairments are noted, including dysphasia, apraxia, visual agnosia,
and dysgraphia.

• The diagnosis of AD is primarily a diagnosis of exclusion. No single clinical test can be

used to diagnose AD.

• At this time there is no cure for AD. The collaborative management of AD is aimed at (1)
improving or controlling decline in cognition, and (2) controlling the undesirable behavioral
manifestations that the patient may exhibit.

• The diagnosis of AD is traumatic for both the patient and the family. It is not unusual for the
patient to respond with depression, denial, anxiety and fear, isolation, and feelings of loss.
The nurse is in an important position to assess for depression and suicidal ideation.

• Currently, family members and friends care for the majority of individuals with AD in their
homes. Others with AD reside in various facilities, including long-term care and assisted
living facilities. Regardless of the setting, the severity of the problems and the amount of
nursing care intensify over time.

• As the patient with AD progresses to the late stages (severe impairment) of AD, there is
increased difficulty with the most basic functions, including walking and talking. Total care
is required.

• Behavioral problems occur in about 90% of patients with AD. These problems include
repetitiveness, delusions, illusions, hallucinations, agitation, aggression, altered sleeping
patterns, wandering, and resisting care. Nursing strategies that address difficult behavior
include redirection, distraction, and reassurance.

• A specific type of agitation is termed sundowning, in which the patient becomes more
confused and agitated in the late afternoon or evening. Behaviors commonly exhibited
include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal
activity such as yelling.

• The person with AD is at risk for problems related to personal safety. These risks include
injury from falls, injury from ingesting dangerous substances, wandering, injury to others
and self with sharp objects, fire or burns, and inability to respond to crisis situations.

• Wandering is a major concern for caregivers. As with other behaviors, the nurse should
observe for factors or events that may precipitate wandering.

• Loss of interest in food and decreased ability to feed self, as well as comorbid conditions,
can result in significant nutritional deficiencies in the patient with AD. Pureed foods,
thickened liquids, and nutritional supplements can be used when chewing and swallowing
become problematic for the patient.

• Urinary tract infection and pneumonia are the most common infections to occur in patients
with AD. Such infections are ultimately the cause of death in many patients with AD.
 • During the middle and late stages of AD, urinary and fecal incontinence lead to increased
need for nursing care.

• AD is a disease that disrupts all aspects of personal and family life. Caregivers exhibit
adverse consequences relating to their employment and to their emotional and physical
health, which then results in family conflict and caregiver strain. The nurse should work
with the caregiver to assess stressors and to identify coping strategies to reduce the burden
of caregiving.

OTHER NEURODEGENERATIVE DISEASES

• Lewy body dementia is a condition characterized by the presence of Lewy bodies
(intraneural cytoplasmic inclusions) in the brainstem and cortex. A common cause of
dementia, it is often unrecognized by health care providers.

• Creutzfeldt-Jakob disease is a rare and fatal brain disorder thought to be caused by a prion
protein. A prion is a small infectious pathogen containing protein but lacking nucleic acids.

• Pick’s disease, a type of frontotemporal dementia, is a rare brain disorder characterized by

disturbances in behavior, sleep, personality, and eventually memory. The major
distinguishing characteristic between these disorders and AD is marked symmetric lobar
atrophy of the temporal and/or frontal lobes.

• Normal pressure hydrocephalus is an uncommon disorder characterized by an obstruction

in the flow of CSF, which causes a buildup of this fluid in the brain.

DELIRIUM
• Delirium, a state of temporary but acute mental confusion, is a common, life-threatening,
and possibly preventable syndrome in older adults.

• Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction
of the patient’s underlying condition with a precipitating event.

• Acute delirium occurs frequently in hospitalized older adults. This transient condition is
characterized by disorganized thinking, difficulty in concentrating, and sensory
misperceptions that last from 1 to 7 days.

• Manifestations of delirium are sometimes confused with dementia. A key distinction

between delirium and dementia is that the person who exhibits sudden cognitive
impairment, disorientation, or clouded sensorium is more likely to have delirium rather than
dementia.

• In caring for the patient with delirium, the roles of the nurse include prevention, early
recognition, and treatment. Prevention of delirium involves recognition of high risk patients.

• Care of the patient with delirium is focused on eliminating precipitating factors. If it is drug-
induced, medications are discontinued. It is important to keep in mind that delirium can also
accompany drug and alcohol withdrawal.

• Care of the patient experiencing delirium includes protecting the patient from harm. Priority
is given to creating a calm and safe environment.
• Comprehensive, multicomponent interventions to prevent delirium are the most effective
and should be implemented through institutional-based programs that are interdisciplinary.