F.

COGNITIVE IMPAIRMENT AND OLDER PERSONS

1. DELIRIUM
 Definition
 A sudden and significant decline in _______________ functioning not better accounted for by a
pre - existing or evolving dementia
 Disturbance of consciousness with reduced ability to __________, __________, and __________
attention

 Causes
 I

 W
 A
 T
 C
 H

 D
 E
 A
 T
 H

 Major Causes
 Underlying medical condition
 Substance intoxication
 Substance withdrawal
 Combination of any or all of these

 Patients at highest risk

 Older adults
 _____ years
 demented
 multiple medications
 Post - cardiac surgery
 Burns
 Drug withdrawal
 AIDS

 Clinical Features
 Prodrome
 Restlessness
 Anxiety
 Sleep disturbance

 Fluctuating course
 Obtunded level of consciousness
 Disorientation
 Agitation
 Short - term memory impairment
 Hallucinations

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  Attentional deficits
 May be able to focus initially, but will not be able to sustain or shift attention
 Easily distracted by the environment

 Arousal/ Psychomotor disturbance

 Hyperactive (agitated, hypervigilant)
 Hypoactive (lethargic, hypovigilance)
 Mixed/ Combined

 Impaired cognition
 Disorganized thinking
 Language Disturbance
 Memory Deficits
 Disorientation

 Sleep - wake disturbances

 Reversal of normal cycle
 Fragmented throughout a 24 - hour period

 Altered perception
 Illusions
 Hallucinations
 Visual
 Auditory
 Tactile
 Gustatory
 Olfactory
 Delusions

 Affective disturbance
 Fear and anxiety
 Irritability
 Depression
 Euphoria
 Lability
 Apathy

 Duration
 Typically, symptoms resolve in __________ days
 May last up to ___ months

 Outcome
 May progress to __________, __________, __________ or __________
 _______________ risk for post - operative complications, longer post - operative recuperation,
longer hospital stays, long - term disability

 Work - up
 History
 Physical assessment
 Focus assessment
 Neuro - science assessment
 Review of medical record

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  Mini Mental State Exam
 Electrolytes
 CBC
 EKG
 CXR
 EEG
 ABG
 SPO2
 Urinalysis
 Culture and sensitivity
 Urine drug screen
 Blood alcohol
 Serum drug levels

 Management
 Identify and treat the underlying etiology
 Increase _______________ and _______________
 Discontinue or minimize dosing of non - essential medications as ordered
 _______________ with physicians and providers
 Monitor and assure __________ of patient and staff
 suicidal ideation and violence potential
 fall and wandering risk
 need for a sitter
 remove potentially dangerous items from the environment
 restrain when other means prove to be ineffective
 Assess individual and family psychosocial characteristics
 Establish and maintain an __________ with the family and other clinicians
 Inform the family that “Delirium is a temporary and part of a medical condition”, and that “the
patient is not crazy”
 Provide post - delirium _______________ and processing for patient
 Environmental interventions
 “Timelessness”
 Sensory impairment and assistive devices
 Orientation cues
 Family members
 Frequent re - orientation
 Nightlights
 Pharmacologic management of agitation
 Low doses of high potency neuroleptics (haloperidol)
 Atypical antipsychotics (risperidone)
 Inapsine (more sedating with more rapid onset than haloperidol as IM or IV, monitor
for hypotension)

 Summary
 Delirium is common and is often a harbinger of death, especially in vulnerable populations
 It is a __________ change in mental status, with a _______________ course, marked by
decreased attention
 It is caused by underlying medical problems, drug intoxication/withdrawal, or a combination
 Recognizing delirium and searching for the cause can save the patient’s life

2. DEMENTIA OF THE ALZHEIMER’S TYPE

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 AGE: 65 years and
Changes in the usual beyond Modification in the
processes of specific GENETICS: mutation on Tau protein takes
proteins in the cell chromosome 21, 14, and place
membranes of neurons 1

Formation of abnormal Tau protein

Formation of intact beta – amyloid protein (BAP) which separates from the
microtubules

Accumulates as amyloid Microtubules fall apart and

fibrils and forms neuritic Tau strands combine to form
plaques neurofibrillary tangles

Proliferation Nerve Eventual Proliferation Quantitative

in the terminal loss of in the reduction in
amygdala degeneration neurons hippocampus choline
acetyltransferase

Personality Cognitive Ventricular Hippocampal Reduction in

changes impairment enlargement function acetylcholine
and mood and from loss of impairment
lability intellectual brain tissue
deterioration Impaired information
processing, acquisition of
Cortical atrophy particularly in new memory, and retrieval of
the parietal and temporal old memories
lobes
 Patients at highest risk
 Older adults
 _____ years
 Family history is another factor
 Genetics
 Co - morbid conditions
 Vitamin deficiency

 Clinical Features
 Alzheimer’s follow an _______________ and _______________ course
 Hallmark symptoms are:
 loss of short - term memory and a denial of such memory loss
 eventual disorientation
 impaired abstract thinking
 apraxias
 changes in personality and affect

STAGE 1 (ONSET) STAGE 2 (CONFUSIONAL) STAGE 3 (TERMINAL)

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 • Memory loss
• Lack of spontaneity
• Subtle personality
changes
• Disorientation to time
and date
• Impaired cognition and • Emaciation, indifference
abstract thinking to food
• Restlessness and • Inability to communicate
agitation • Urinary and fecal
• Wandering incontinence
“__________________” • Seizures
• Inability to carry out
activities of daily living
• Impaired judgment
• Inappropriate social
behaviour
• Repetitive behaviour
• Voracious appetite

 AAMI vs. Alzheimer’s

AGE – ASSOCIATED MEMORY IMPAIRMENT ALZHEIMER’S DISEASE

Forgets part of an event but often remembers
later
Usually able to follow written or spoken
directions
Usually able to use notes as a reminder
Usually able to care for self
Forgets entire events but rarely remembers later
Gradually unable to follow written or spoken
directions
Gradually unable to use notes as a reminder
Gradually unable to care for self

 Duration
 The terminal phase of the disease may last from a few months to several years

 Outcome
 How quickly Alzheimer’s worsen is different for each person, and if it develops quickly, it is more
likely to worsen quickly
 The patient becomes totally _______________ during the terminal phase
 Patients often die earlier than normal, although a patient may live anywhere from _______ years
after diagnosis
 Death usually occurs from an infection or organ failure

 Work – up
 Alzheimer’s is essentially a diagnosis of exclusion
 There are no peripheral biochemical markers or tests for the disease
 The diagnosis can be confirmed only by ______________________________ of tissue obtained
from a cerebral biopsy or autopsy
 The diagnosis then is based on ______________________________
 The diagnosis of Alzheimer’s disease requires the presence of dementia established by clinical
examination and documented by results of a Mini - Mental Status Examination, Blessed
Dementia Test, or similar mental status tests; no disturbance in consciousness; onset between
ages 40 – 90, most often after age 65 years; and absence of systemic or brain disorders that
could account for the memory or cognitive deficits
 Brain imaging, CT scan, or MRI
 Metabolic screening

10 WARNING SIGNS OF ALZHEIMER’S

1. Memory loss

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 2. Problems with abstract thinking
3. Difficulty performing familiar tasks
4. Disorientation to time and place
5. Poor or decreased judgment
6. Trouble understanding visual images and spatial relationships
7. New problems with words in speaking or writing
8. Misplacing things and losing the ability to retrace steps
9. Withdrawal from work or social activities
10. Changes in mood and personality

 Management
 Build a solid foundation of _______________ of Alzheimer’s Disease
 Non - pharmacologic interventions
 __________: an anti - inflammatory diet rich in fruits, vegetables, whole grains, fatty fish
and non - animal protein sources like beans and whole soy foods, limiting animal proteins, as
well as white flour foods and sugar
 __________: at least 30 minutes of activity several days a week which could significantly
improve memory; the more the patient exercises, the greater the benefit
 ____________________: includes B - vitamins, zinc, phosphatidylserine, ginkgo, coenzyme
Q10, bacopa, lemon balm and vinpocetine (University of Maryland Medical Center)
 Pharmacologic interventions
 _____________________________________________: Donezepil hydrochloride (Aricept),
Rivastigmine hydrogren tartrate (Exelon), Galantamine (Reminyl)
 ____________________________________________________________: Memantine
Hydrochloride (Abixa)

 Nursing intervention
 Memory boosters
 Identify conditions that can affect sensing, interpreting, and communicating stimuli such as
cognitive impairments
 Observe for behavioural responses such as hostility, crying, confusion, and disorientation
 Assess attention span, distractibility, and ability to make decisions or solve problems
 Evaluate skill proficiency levels including self - care activities
 Reorient to person, place, time, and events as necessary
 Providing a calm environment by removing extraneous noise
 Provide safety measures such as close supervision
 Provide memory cues
 Give simple directions, using short words and simple sentences.
 Allow to keep to their regular routine all the time
 Have them keep written tracks of recent visitors
 Have them recall past events important to them
 Set limits on unsafe and inappropriate behaviour
 Schedule activities and rest periods
 Do not challenge illogical thinking
 Avoid provocative stimuli, negative criticisms, arguments, and confrontations
 Encourage ventilation of feelings of frustration and helplessness
 Social Interaction
 take time to __________ the patient
 provide activities to help stimulate the mind and alleviate boredom
 keep them occupied with social activities and interactive games geared to their capabilities
 make them feel safe and less anxious in the presence of other people and residents
 provide opportunities for re - socialization
 Home Care

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  create living conditions that are as stress - free as possible
 be very patient with them, talk with them, ask them how they feel or what they want to eat
which shows respect that they need and deserve
 Other interventions
 limit choices to those which the individual can make by using close - ended questions
 redirect or distract the person who is delusional instead of correcting or confronting him or
her
 pain assessment should be included in the ongoing plan or approach to caregiving
 slow down, speak clearly, make eye contact, and stay in the person’s field of vision

 Summary
 People with dementia are likely to respond differently to the variety of psychological and
pharmacological management strategies
 Caregivers need to be aware of the full range of interventions, know which ones may be most
appropriate for an individual, and understand how to recognize whether an intervention is
helping
 The principal focus of care should be to _____________________________________________
and ______________________________
 ______________________________ should be at the heart of all effective psychological
interventions
 Ultimately, caregivers should provide _______________ that encourages the patient to maintain
as much independent functioning as possible, which is perhaps as important as any specific
interventions for cognitive symptoms

3. DEPRESSION

 Definition
 is one of the most _______________ and most _______________ of all mental disorders in
older adults
 is a major health concern in this population and can be ______________________________ if
unrecognized and untreated
 is among the mental disorders most commonly seen and treated by advanced practice
gerontological nurses
 describes many things, including a mood state, a disease, a syndrome, and a symptom
 The National Institutes of Health (NIH) Consensus Development Panel on Depression in Late Life
says that it is “a syndrome that includes a ____________________ of physiological, affective,
and cognitive manifestations.”

 Classification
 MAJOR DEPRESSIVE DISORDER: characterized by one or more major depressive episodes
 DYSTHYMIC DISORDER: characterized by at least __________ of depressed mood for more days
than not, accompanied by additional depressive symptoms that do not meet the criteria for a
major depressive episode
 BIPOLAR DISORDERS: Bipolar I disorder is characterized by one or more __________ or
__________ episodes, usually accompanied by major depressive episodes. Bipolar II disorder is
characterized by one or more major _______________ episodes, accompanied by at least one
_______________ episode
 MOOD DISORDER DUE TO A GENERAL MEDICAL CONDITION: characterized by a prominent and
persistent disturbance in mood that is judged to be a direct physiological consequence of a
general medical condition

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  SUBSTANCE - INDUCED MOOD DISORDER: characterized by a prominent and persistent
disturbance in mood that is judged to be a direct physiological consequence of a drug of abuse, a
medication, another somatic treatment for depression, or toxin exposure
 SUBSYNDROMAL DEPRESSIVE SYMPTOMS: characterized as depressive symptoms that do not
meet the criteria for major depression that nevertheless affect their _______________ of life
and may lead to more _______________ mood disorders
 SEASONAL AFFECTIVE DISORDER (SAD): characterized as onset and remission of major
depression which occurs at characteristic times of the year, and a cyclical illness characterized by
depressed periods beginning in the _____ and subsiding in the _______

 Patients at highest risk

 actual or perceived __________
 Illness
 impaired mobility
 changes in sensory capacity
 social isolation
 death of a spouse or friends
 economic hardships
 Retirement
 _______________ bereavement
 _______________ major life events

 Clinical Features
 Depressed mood
 ____________________
 Unintentional weight change of 5% or more in a month
 Change in sleep pattern
 Agitation or psychomotor retardation
 Tiredness
 Worthlessness or guilt inappropriate to the situation
 Difficulty thinking, focusing, or making decisions
 Hopelessness
 Helplessness
 Suicidal ideation

 Work - up
 There is no single diagnostic test recommended for the detection of depression in older adults
 The assessment is a challenging process of _______________ the complex interplay among
physical, mental, social, economic, spiritual, environmental, and treatment - related factors
 thorough history
 review of medications and alcohol use
 physical examination

 Management
 The goal of treatment for an older depressed person includes the improvement of
____________________ and ______________________________ and the reduction of
_______________ and _______________
 Other treatments goals include improving medical _______________ status and decreasing
_______________ of depression, the risk of _______________ and _______________, and
______________________________ and _______________
 Biological treatment (somatic therapies)
 Pharmacologic treatment

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 - Selective Serotonin Reuptake Inhibitor (SSRI): Citalopram, Fluoxetine
- Serotonin – Norepinephrine Reuptake Inhibitors (SNRI): Desvenlafaxine, Duloxetine
- Noradrenergic and Specific Serotonergic Antidepressants (NaSSAs): Mianserin,
Mirtazapine
- Norepinephrine Reuptake Inhibitors (NRIs): Atomoxetine, Mazindol
- Tricyclic Antidepressants (TCAs): Amitriptyline, Clomipramine
- Monoamine Oxidase Inhibitors (MAOIs): Tranylcypromine, Isocarboxazid, Phenelzine

COMMON ANTIDEPRESSANT SIDE EFFECTS AND INTERVENTIONS

SIDE EFFECTS INTERVENTION
• Reassure that it is a temporary side effect
Blurred vision
• Provide support and assistance as necessary
• Check for environmental hazards if needed
• Increase water and fluid intake
• Suggest “natural” dietary laxatives
Constipation • Request prescription softeners
• Monitor bowel habits to avoid impactions
• Use laxatives only as a last resort
• Encourage fluids to reduce discomfort
• Check dentures for proper fit
Dry mouth
• Monitor for sores or lesions that may cause discomfort and
interfere with eating
• Monitor voiding patterns and assess for subjective distress
• Monitor color and odor of urine
Urinary retention
• Report findings to physician for possible catheterization and
medication change
• Offer comfort measures
Excessive perspiration
• Inform residents that “sweating” is a side effect of medication
• Take lying and standing blood pressures for 2 - 3 weeks when the
medication is started
• Monitor for dizziness and light - headedness
• Inform client that this is a side effect of the medication and that
Orthostatic hypotension
falls may occur if client gets up too quickly
• Instruct client to dangle feet over side of bed when getting up
from a reclining position and to rise slowly and stand supported
for a few minutes before walking
• Administer medications at hour of sleep to facilitate sleep and
reduce daytime drowsiness
• Monitor level of sedation and fatigue over time to differentiate
Fatigue, weakness, and between medication side effects and symptoms of depression
drowsiness • Access activities of daily living and activity level for declines
• Monitor sleeping patterns for increased daytime sleeping
• Notify physician if symptoms seem to worsen as medication is
increased
• Monitor severity and interference with activities of daily living
and other activities
• Assess subjective distress
Tremors, twitches,
• Provide information and encouragement that this is a medication
jitteriness
side effect - not a permanent impairment - that will subside when
the medication is discontinued
• Notify the physician if symptoms are prolonged or severe
Hallucinations and • Establish onset to differentiate between “psychotic depression”

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 and medication side effect
• If associated with medication, hold additional doses and notify
physician
• Monitor for safety and provide reassurance if hallucinations or
delusions delusions are frightening or upsetting
• Provide reality orientation
• Recognize that belief seems real to them but is actually an
adverse side effect of the medication, that will soon go away, and
that you will keep them safe until then

 Electroconvulsive therapy (ECT)

 Phototherapy
 Psychotherapy
 Behavioral therapy
 Cognitive therapy
 Brief psychodynamic therapy
 Interpersonal therapy
 Supportive therapy
 Interact with the patient as often as possible
 Make _______________ and _______________ referrals to mental health professionals
 Communicate caring
 Assist the elderly to see if they are unusually sad or blue
 Provide _______________ information about depression
 Modify the physical or social _______________
 Other research - based treatment
 Group therapy
 Guided imagery
 Therapeutic touch
 Massage

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