EFFECTS OF DEMENTIA ON THE ELDERLY POPULATION 2

Abstract

Dementia is becoming more and more common in aging men and women. Although many

research studies have been performed, there is much we do not know about this health disparity.

We are still struggling to provide quality of life to these patients as well as avoid further

complications. As future nurses, we are taught to be an advocate for our patients and to provide

comprehensive care using our acquired skills and ethical judgements. This can sometimes prove

to be a daunting task. This case study will take an in-depth look at a patient in a geriatric

psychiatric unit to explore her illness as well as possible precipitating factors. Nursing

diagnoses, interventions, outcomes, and evaluations will be included. It will also address some

of the significant effects that dementia can have on a patient and potential treatment options

available, incorporating her needs during her acute hospital stay as well as after discharge.
EFFECTS OF DEMENTIA ON THE ELDERLY POPULATION 3

Dementia Effects on the Aging Population

According to Hui En Tay, Thompson, Ming Nieh, Chiang Nieh, Mien Koh, Cheen Tan, & Kiat

Yap (2018), “Patients with dementia are often subjected to enforced dependency and experience

functional decline and emotional distress during hospital stay”. This stems from the confusion in

unfamiliar surroundings and people, as well as medical procedures and treatments that they may

not understand. Not only can hospital stays negatively affect dementia patients, their daily life is

also adversely changed in many ways. They sometimes can no longer perform activities of daily

living on their own. Their own personal safety can come in to jeopardy when completing simple

tasks such as cooking or bathing. They pose a potential danger to themselves if they wander

from their home. The impacts of this illness can vary depending on what form of dementia the

patient suffers from. However, in all cases, their cognitive abilities face severe deterioration in

areas such as memory, learning, attention, and language skills.

Literature Review

Introduction

Dementia is not a specific disease, but several illnesses classified together which manifest

themselves a disruptions in brain functioning. Theses illnesses include delirium as well as

amnesia. Acute altered mental status is considered delirium, while dementia is defined as a

chronic altered mental status. Many triggers can cause altered mental status, including endocrine

dysfunction, drug toxicity, trauma, stroke, brain ischemia, encephalitis and sepsis. Ultimately,

these disturbances in brain function affect cognition in several areas of functioning by not

allowing the cells to communicate normally. It is a progressive disease that may improve with
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the successful treatment of underlying conditions such as depression, medication side effects,

and thyroid problems.

Objective Data

The focus of this case study is on patient CW, date of care March 2, 2018 . She is an 82 year old

female residing in Warren, Ohio. She presented to the emergency room on March 1, 2018 upon

removal from the restaurant Eat N’Park by police for causing a disturbance. She is reported to

have frequented this establishment on regular occasions, at times begging the staff and customers

for money or food. After admission to the cardiac telemetry unit for an elevated troponin level,

she was noted to be agitated, climbing on the bed and yelling at the medical staff. A widow

living alone in a high-rise apartment building, she has no children or living relatives to assist in

her care and welfare. Her caseworker through Scope indicates that she needs evaluated for her

ability to perform activities of daily living. She was transferred to the geriatric psychiatric unit

for an involuntary admission after being medically cleared of any cardiac issues. Her toxicology

screen returned normal results. She is suspected of being non-compliant with her medication due

to confusion or financial hardship.

Her health history includes a previous myocardial infarction, transient ischemic attack,

hypertension, hiatal hernia, and pulmonary fibrosis. She has suffered several falls in the past,

sustaining a compression fracture in 2014. She also has a pressure wound present on her right

ischial region as well as a pinhole-sized wound on her distal coccyx.

Upon assessment, the patient was oriented to person and place. She stated her current location as

“in the hospital”, but did not know what city or state she was in. Her facial expressions showed

listlessness and possible depression. She was dressed neatly with relaxed posture and gestures,
EFFECTS OF DEMENTIA ON THE ELDERLY POPULATION 5

although her hair was unkempt and she appeared to have many dental problems. However, she

was friendly and willing to answer any question that was asked. Her speech was clear, non-

garbled and her answers were appropriate but she had difficulty recalling past information and

events. She currently weighs 88 lbs. Her bloodwork showed abnormal results with high carbon

dioxide levels and deficit calcium, albumin, and ALT. The medications currently prescribed to

this patient for daily use are aspirin, Celexa, and Seroquel. The medications presribed on an as-

needed basis are Tylenol, Dulcolax, Haldol, Vistaril, Duoneb, Milk of Magnesia, Zofran, and

Desyrel.

Psychiatric Diagnoses

Patient CW exhibits many of the classic signs of her medical diagnosis of dementia. According

to Kales, Gitlin, & Lyketsos, (2015), “behavioral and psychological symptoms of dementia

include agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep

problems, wandering, and a variety of inappropriate behaviors” (p. 1). Her diagnosis is

evidenced by disorientation, agitation and aggression with medical staff, and stating she is “too

stressed to eat”. She also exhibits periods of delusional thinking, telling the police officer that

she was a sheriff as well as stating that a staff member at Eat N’Park wants to marry her.

Kale et al also states that “people with dementia may be disproportionately affected by pain and

undiagnosed illnesses compared with those without cognitive impairment” (p. 4). The patient

has not yet been diagnosed with depression or other illnesses that could contribute to her current

state of cognition. Her recent health issues such as the wounds on her ischial region could be

causing her pain which thus far has not been treated. She also has an abnormal carbon dioxide

level which could be contributing to her lower cognition level due to difficulty maintaining her

oxygen saturation.
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The progression of patient CW’s confusion can be attributed to dehydration, malnutrition, and

inadequate support in her current living situation. Kales et al notes that “the loss of ability to

express needs or goals verbally leads the person with dementia to communicate and express

needs through various behaviors” (p. 4). She does not manage her own finances and often has no

food in her home. Her solution is to venture down to Eat N’Park where she may be able to

obtain a meal or convince a kind person to donate money for food and cab fare.

Stressors and Triggers

Patient CW’s current hospitalization stemmed from the strange behavior she displayed while at

Eat N’Park. She began begging patrons and staff for food as well as money. This created a

disturbance which led to police involvement. She was escorted to the hospital for evaluation.

She has many stressors that may have contributed to her psychosis. Her husband passed away

from cancer several years ago, which was her only familial support. She states that she spends

her days watching television and visiting Eat N’Park. She also states she is “losing interest in

activities” that she once found pleasing. She spends most days being isolated from the outside

world other than small interactions she may have with cab drivers and staff members at the

restaurant. “With decreased ability to process stimuli, the stress threshold of the person with

dementia becomes lower and the potential for higher levels of frustration increases; if unabated,

serious anxiety and severe agitation can develop”, (Kales et al, 2015, p. 4). This is evidenced by

her behavior in the restaurant as well as after her admission to the hospital.

Financial stressors play an immense part in her dementia as well. She is currently utilizing

government assistance through Medicare and Medicaid for her health care coverage. She also

receives a social security stipend each month to help pay for her apartment rental fees and
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utilities. Her finances are handled by a caseworker, which surely makes her feel a loss of

control.

Patient and Family History of Mental Illness

The patient’s health history includes several instances of unusual behavior that could indicate

psychiatric problems. During the interview, she stated that “people keep stealing my movies”,

referencing a movie collection she once had that she cannot find. She has a history of paranoid

behavior, using tape to cover her door because she believed she was being watched. She would

also not allow a representative from Adult Protective Services into her home in fear that this

person was coming to harm her.

No family history was noted demonstrating familial links with mental illness. The patient could

not recall any such information, and no living relatives have been located.

Evidenced-Based Nursing Care

The patient attended a group therapy session on the day of the interview. The therapy was

hosted by two of my fellow students. They initiated a bingo game with suggested coping

mechanisms. The patient offered little participation but was present for the entire session. She

also completed physical therapy on the day of care. A social worker spoke with the patient to

determine her ability to care for herself after her hospital stay. The social worker was able to

establish a rapport with the patient. She was kind and seemed to gain the patient’s trust. At the

conclusion of the interview, the patient was informed that she would most likely be placed in an

assisted living facility upon discharge. The patient seemed relieved but stated “I feel worried”

when asked about her thoughts by the social worker. Medications were provided to the patient
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as well as an opportunity to perform self-care activities such as brushing her hair and teeth and

changing clothes.

Ethnic, Spiritual, and Cultural Influences

Patient CW was not very forthcoming regarding other influences in her life. The patient

disclosed that she practiced in the Catholic faith as a child, but has not attended a religious

ceremony in quite some time. She could not recall what her ethnic background was and stated

no cultural impacts on her current situation. Recent research studies have concluded different

factors which may correlate to ethnic groups not seeking treatment. According to Mukadam,

Cooper, & Livingston (2011), “barriers included personal reactions such as denying there was a

problem, community stigma, a sense of familial responsibility and healthcare related barriers

such as language barriers, feeling discriminated against and believing nothing could be done to

help” (p. 18). Although this patient is a white female, there is still a stigma surrounding issues

with mental health. That may have contributed to her current mental state as she was non-

compliant with her treatment prior to her hospital stay. Her sense of losing control may also left

her feeling that nothing could be done to improve her situation or condition.

Patient Outcomes

The most important favorable outcome is for this patient to be transferred to an assisted living

facility, as she is in desperate need of assistance to maintain the best quality of life. She will no

longer face isolation and try to care for herself on her own. At this facility, she will be able to

socialize with peers, have appropriate medical treatment, continue with multiple therapeutic

modalities, and be provided with a safe environment in which she can begin to enjoy the things

she loves again. She will be able to practice compliance with all her ordered treatments,
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including medications as well as physical and occupational therapy. Kales et al (2015) states

“several randomized trials have found that engagement in physical activity and pleasant events

reduced depression in persons with dementia living at home” (p. 5) I believe that the same holds

true for patients in other living situations, including assisted living facilities.

Discharge Planning

According to Kales et al, “Because of the complex causes of behavioral and psychological

symptoms of dementia, a ‘one size fits all’ solution does not exist” (p. 5). This patient will need

individualized care after discharge. Upon release from the hospital, this patient will continue her

daily medications as prescribed. She will be placed in a nursing facility to address the multiple

difficulties she faced while living on her own. Her malnutrition and dehydration will be treated

in the rehabilitation facility, as these health disparities will require long-term supervision and

assessment. Psychiatric therapy and counseling should also be included as part of her discharge

plan. Other interventions of her discharge plan should focus on increased socialization to

minimize isolation, cognitive therapy for improved memory and cognitive function, wound care

to prevent complications and infection, fall precautions, and pain management. Occupational

and speech therapy may also be considered.

NANDA Nursing Diagnoses

Several nursing diagnoses are appropriate for patient CW. The highest priority is Risk for Injury

related to diminished mental status as evidenced by orientation to person and place only. The

next significant nursing diagnosis is Imbalanced Nutrition: Less than body requirements related

to unwillingness to eat as evidenced by recent weight loss. Next, Self-Care Deficit related to

activity intolerance as evidenced by decreased ability to perform activities of daily living. Also
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significant would be the diagnosis of Impaired Skin Integrity related to physical immobilization

as evidenced by disruption of skin surfaces. Another important nursing diagnosis is Impaired

Memory related to neurological disturbances as evidenced by inability to recall information and

events.

Potential NANDA Nursing Diagnoses

Potential nursing diagnoses could include Acute Confusion related to hypoxia as evidenced by

increased carbon dioxide levels. Yet another possible diagnosis would be Impaired Swallowing

related to neuromuscular impairment as evidenced by repetitive swallowing. An additional

nursing diagnosis may be Disturbed Sleep Pattern related to sundown syndrome as evidenced by

a change in normal sleep pattern. Lastly, Constipation related to inactivity as evidenced by

hypoactive bowel sounds.

Conclusion

Kales et al states that “Dementia was estimated to affect 44 million people worldwide in 2013.

This number is expected to reach 76 million in 2030 and 130 million by 2050” (p. 2). Patient

CW is one of millions of people who suffer from this debilitating illness around the world. We

must also address the financial burdens and the stressors of this illness on the caregivers.

Oftentimes it is the family members who ultimately suffer the most from this disease, watching

their loved one progressively deteriorate. Support services must be enacted and encouraged.

Education is also a key factor of this illness.

In conclusion, Kales et al states, “An evidence based approach is needed that can detect and

manage symptoms, carefully consider possible causes, and then integrate pharmacological and

non-pharmacological treatments” (p. 9). As health care professionals we must keep actively
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searching for improved treatments to provide our patients with the best medical care and quality

of life possible through continued research and successful interventions.

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References

Hui En Tay, F., Thompson, C.L., Ming Nieh, C., Chiang Nieh, C., Mien Koh, H., Cheen Tan,

J.J., & Kiat Yap, P.L. (2018). Person-centered care for older people with dementia in the

acute hospital. Alzheimer’s & Dementia: Translational Research & Clinical

Interventions, 4, 19-27.

Kales, H., Gitlin, L., & Lyketsos, C. (2015). Assessment and management of behavioral and

psychological symptoms of dementia. BMJ, 1-16.

Mukadam, N., Cooper, C., Livingston, G. (2011). A systematic review of ethnicity and pathways

to care in dementia. International Journal of Geriatric Psychiatry, 26, 12-20.