Page 77 Complete Your CE Test Online - Click Here Dementia Dementia is a syndrome that leads to a progressive decline in multiple cognitive abilities. The presenting signs and symptoms range from mild cognitive impairment to complete incapacitation. Dementia is both chronic and terminal, since the syndrome progresses until causing the patient to become completely dependent in all aspects of activities of daily living. There is no consistent course and no predictability of the rapidity with which the disease will progress [9]. Dementia primarily affects older adults, but it is not a normal part of aging. It is a significant world-wide problem, affecting about 47.5 million people. Experts predict that this number will increase to 75.6 million by 2030, and 135.5 million by 2050 [34]. There are four major groups of dementia [9]: ● ● Alzheimer’s disease (AD): This is the most common cause of dementia and accounts for 80% of dementia diagnoses. AD has an insidious onset and impacts all aspects of patients’ lives. ● ● Vascular dementia (VaD): VaD is the second most common type of dementia and usually has an abrupt onset and is believed to be caused by cardiovascular problems. ● ● Lewy body dementia: This type of dementia includes Parkinson’s disease with dementia (PDD) and dementia with Lewy bodies (DLB). It is characterized by the presence of round structures called Lewy bodies and neuritis found in the brain. Patients exhibit visual hallucinations, delusions, and extrapyramidal symptoms. ● ● Frontotemporal lobe dementia: This type of dementia includes Pick’s disease, a dementia that usually occurs in late middle age and involves localized frontotemporal brain atrophy. It is characterized by personality changes. The fifth edition of The Diagnostic and Statistical Manual of Psychiatric Disorders (DSM-5) no longer addresses dementia as a single disorder [35]. Instead, there is a section devoted to Neurocognitive Disorders (NCD), which in the fourth edition was referred to as delirium, followed by syndromes of major NCD, mild NCD, and their etiological subtypes. Nursing consideration: Here is some additional information about the use of the term dementia in the DSM-V. “The term dementia is retained in DSM-V for continuity and may be used in settings where physicians and patients are accustomed to this term. Furthermore, the major NCD definition is somewhat broader than the term dementia, in that individuals with substantial decline in a single domain can receive this diagnosis, most notably the DSM-IV category of ‘Amnestic Disorder’ which would not be diagnosed as major NCD due to another medical condition and for which the term dementia would not be used.” – American Psychiatric Association, (2013, p 591) [35]. Six domains are used to determine the stage of dementia. These domains are memory, orientation, judgment and problem solving, community affairs, home and hobbies, and personal care. Diagnosis is based on assessment of these domains and a thorough history and physical since there are not definitive diagnostic studies that can confirm diagnosis. Diagnostic tests such as blood work or imaging are generally used to rule out or identify other diseases that may be causing signs and symptoms of dementia or exacerbating such signs and symptoms [9]. Treatment interventions vary depending on the stage of dementia and are aimed at slowing the progression of the dementia and improving cognitive function. The U.S. Food and Drug Administration (FDA) approved drugs (as of this writing) are [37]: ● ● Donepezil (e.g., Aricept). ● ● Galantamine (e.g., Razadyne). ● ● Memantine (e.g., Namenda). ● ● Rivastigmine (e.g., Exelon). ● ● Donepezil and mematine XR (e.g., Namzaric). Nursing consideration: Nurses have an obligation to stay up-to- date regarding advances in pharmacological treatment of dementia. This involves a definite effort to pursue personal, ongoing continuing education regarding dementia. Dementia vs. delirium Although delirium and dementia can exhibit similar symptoms, they are two very different disorders. We discussed dementia above as a progressive disease manifesting in a decline in memory and at least one other cognitive area in an older adult. Delirium is an acute disorder affecting attention and global cognition (memory and perception) and is treatable. Before a diagnosis of dementia is made, delirium must be ruled out. There are many common causes or risk factors for delirium. These can be identified easily with the mnemonic DELIRIUM [38]: ● ● Dementia. ● ● Electrolyte disorders. ● ● Lung, liver, heart, kidney, brain. ● ● Infection, especially UTI or pneumonia. ● ● Rx (prescription or other) drugs, especially opioids. ● ● Injury, pain, stress. ● ● Unfamiliar environment, i.e., hospitalization. ● ● Metabolic and constipation. Assessing for older adult abuse Mrs. Douglas is 80 years old and lives with her daughter, son-in-law, and three grandchildren. She was recently hospitalized after undergoing a total hip replacement and subsequent infection of the surgical wound. After discharge, she returned to her daughter’s home. A visiting nurse arrives this morning to assess Mrs. Douglas’s wound and perform a dressing change. Mrs. Douglas lives in a self-contained apartment attached to the main house via a short hallway. Her daughter provides Mrs. Douglas with housecleaning services and brings her meals three times a day. Mrs. Douglas’s apartment is spotlessly clean. Mrs. Douglas is dressed in a clean housedress, and is wearing make-up and jewelry. She does not make eye contact with the visiting nurse and has a sad expression on her face. Her daughter is present and interacts with the visiting nurse, asking if her mother is “healing”, but she does not interact with Mrs. Douglas. One of the grandchildren stops in to ask for a ride to a sports event. The grandchild does not interact with Mrs. Douglas, but rolls her eyes and mutters something about “that old woman is more trouble than she’s worth.” Mrs. Douglas’s daughter prepares to leave and casually thanks the nurse for coming. She does not speak to her mother. Mrs. Douglas looks at the visiting nurse and says sadly, “They take care of me but no one really cares about me. There is no love. They don’t like me and make fun of me. They only see me when they absolutely have to. I’m always alone.” Mrs. Douglas is suffering from emotional neglect and possible emotional abuse. When nurses hear the term “elder abuse” they often picture an older adult who is bruised, in poor physical condition, and may be dressed in dirty clothing. But there are many forms of abuse, not all of them readily apparent. Elder or older adult abuse can take place in any setting: the patient’s home; an acute care hospital; or long-term care facility. It occurs in all socioeconomic groups. Nurses must be aware of the various types of abuse and how to protect the older adult from the effects of abuse. Physical abuse Physical abuse is defined as the use of physical force to intentionally inflict physical injury or pain. Actions such as hitting, pushing, slapping or shaking are forms of physical abuse [9]. Restraining by physical or chemical means and even confinement are also types of physical abuse [37]. Signs of physical abuse include bruising, fractures, abrasions, lacerations, and cuts. But it can be difficult to distinguish accidental injury from physical abuse. The older adult’s skin contains only small amounts of subcutaneous fat and blood vessels are thin and fragile [14]. This makes the older person susceptible to accidental bruising, which can be difficult to distinguish from physical abuse. Bruising after an accidental fall, for example, is not related to abuse. There are, however, indicators that are suggestive of physical abuse [39,40,41]: ● ● Accidental bruises rarely, if ever, occur on the neck, ears, genitals, buttocks, or soles of the feet.