Nursing management of geriatric patients with dementia

8/7/2019 Nursing management of geriatric patients with dementia

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GERIATRIC CAREMANAGEMENT


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Chronic Health Conditions


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Geriatric Care Management

Care Management: A response to: Diagnostic Related Groups DRGs The Expanded Role of the Nurse-Discharge Planner

Social Work failing to respond to the demands of health

Perception as a cost center Inability to calculate or articulate cost savings

Case Managers in Health Care Employed by health care system, working for the health care

system; not for the patient

People, especially older adults can not effectively andefficiently navigate the system Family support is very different today than yesterday


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Care Management &

Systems Theory

Older adults seldom age in a vacuum and are

frequently members of family systems

Health care is the combination of multiple

systems (acute, rehab, home, etc.)

Change in one piece of a system, forces

change in the entire system

Every member in system has an establishedrole and acts accordingly

When the system is out of balance, it

provides the opportunity for change


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Defining Geriatric Care

Management

Care ManagementCase Management

Care Coordination


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Involving thefamily in geriatric

care


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It All Starts and Ends With

Assessment

The assessment of the

client (the entire client

system) is an ongoing

process that only endswhen the case is closed


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Engagement is the

Foundation

Engage the client, not the diagnosis

Go slow

Dont make promises

Respect their right to disagree

Determine who the other members

of the family system Engage them as soon as possible


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Engaging the rest of the Client

System Watch the process Let the pathology act out

Assess for the strengths

Everyone has strengths, some just dont know it Educate

Provide accurate information

Facilitate

Help the process to move on Integrate

Bring the pieces together


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Geriatric Assessment

COGNITIVE STATUS

Mini-Mental Status Exam

Evaluate Ability to Understand Options andImplications of Alternatives; Capacity

FUNCTIONAL STATUS

Activities of Daily Living

Instrumental Activities of Daily Living


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EMOTIONAL STATUS

Obtain a complete psychiatric

history of treated and UN-

TREATED symptoms;- Depression

- Anxiety

- Presence of other PsychiatricSymptoms


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Medical Status

Detailed history of medical care

Who, what where, and when

History of clients response to pastevents

Reactive vs. Proactive

Significant changes contributing tocurrent condition

Who are the members of the clientshealth care team


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SOCIAL STATUS

Social Networks

Size of network

Expectations Proximity of network

Ability of network

Competing role demands

Use a Social Eco-Map to VisuallyPresent Strengths/Barriers


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Cultural/Religious Factors Provides guidelines

Preferences for care alternatives

Identify potential sources of conflictrelated to care

Guidelines for Advance Directives

Anticipate the unexpected Prepares client/family with

information to make important

decisions


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Environmental Assessment

Given a choice, most indicate they want

to Age in Place

Home Safety Assessment Cleanliness Flooring, Kitchen, Bath, Bed and

Living Rooms Electrical/Lighting/Heating/Cooling/Cooking

Ask for complete tour (part of physical assessment)

Will what works today, work in the future?


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THE CAREPLANNING

BALANCING ACT

When Preparing a Care Plan You MustBalance the Needs of:

The Patient

The Family/Other Informal Caregivers

Formal Caregivers

Society/Policy Makers


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Strengths Based Care Plan State in positive terms what client is going

to do, rather than stop doingMary will call her daughter when she is low on

groceries

Be realistic and achievable

Mary will use her walker to retrieve the mail

Measurable and visible reflecting one stepat a time

Tom will take his meds during Wheel of Fortune


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Strengths BasedCare Plan(continued)

Specific and time limited no longer than 3months and broken down into small steps

Tom will attend exercise class at the Senior Center

twice a week.

Relevant and understandable to client

Betty will call her granddaughter Sue each week for a ride to her

sewing circle.

Chapin, R & Fast, B. Strengths-Based Care Management for Older Adults.


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CARE PLAN

CONSID

ERATIONS Utilization of formal services

Accessibility

Acceptability

Adaptable

Appropriate

Perception of need

Patient

Family

Provider/Agency


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Goals

Epidemiology

Memory in typical aging

Mild cognitive environment


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Nursing

management ofgeriatric patientswith dementia


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Dementia is the most common psychiatricdisorder on the later age. It is anirreversible disorder.


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How do wehandle dementia

in geriatricpatients?


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Geriatric patients usually have a hardertime doing the ADLs of everyday

Geriatric patients with dementia have aharder time of doing normal activities.


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In assessing the presence or absence of dementiaspecial care should be taken to avoid false,

positive, identification motivational or emotionalfactors. Dementia produces an appreciabledecline in intellectual functioning, interference

with personnel activities of daily living such aswashing, dressing, eating, personal hygiene,

excretory and toilet activities changes in roleperformance occur such as lowered ability tokeep or find job should not be used as criteria ofdementia because of the large cross cultural

difference exist in appropriate because frequent,externally imposed changes in the availability orwork.


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SOME CAUSESOF DEMENTIA A. Degenerative diseases of the central Nervous System.

Senile dementia

Alzheimers disease

Picks disease

Huntingtons chorea

Parkinsons disease

Creutzfeldt Jakob disease

Normal pressure hydrocephalus

Multiple sclerosis

Lewy body disease


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B.Intra Cranial Causes Space occupying lesions Tumors

chronic subdural haematomas chronic abscesses aneurysm

C. Vascular causes Multi-infarct dementia.

Occlusion of the carotid artery

Stroke

Hypertension

Cranial arthritis


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D. Metabolic and endocrine disorders :- Endocrinopathies Addisons disease, Cushings syndrome, Hyperinsulinism, Hypothyroidism, Hypopituitarism, Hyperparathyroidism, Hyperparathyroidism.

Hepatic failure

Renal failure

Renal dialysis

Respiratory failure

Hypoxia

Chronic uremia.

Chronic electrolyte imbalance.

Hypocalcaemia

Hypercalcaemia

Hypokalaemia

Hyponatraemia

Hyper natraemia

Remote effect of Carcinoma or Lymphoma.


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G.Infections and related conditions: -

Encephalitis of any cause

Neurosyphilic Chronic Meningitis

Cerebral Sarcoidosis

Cysticercosis

AIDS and AIDS related complex.


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H.Toxic Causes :

1. Alcohol2. Poisoning with heavy metals lead,arsenic, thallium, mercury, carbonmonoxide.

3. Drug and alcohol withdrawal ofanxiolytic sedative drugs, amphetamine.


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I.Anoxia:-

1. Anemia

2. Post anesthesia3. Cardiac arrest4. Chronic respiratory failure


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Types of dementia- an overview

A. CORTICALAND SUB CORTICALDEMENTIA

Dementia may be associated with multiple

sub cortical or cortical infarcts and clinicalfeatures vary according to that. Non-Alzheimers dementia basically meanssub-cortical dementia. Somedistinguishing features of sub cortical andcortical dementia are as follows:


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Sub cortical dementia Cortical dementia

1. Language No aphasia Aphasia early

2.. Memory Impaired recall>recognition Recall and recognition impaired

equally

3. Attention and immediate recall &

visuospatial skills

Impaired Impaired

4. Calculation Preserved until late Involved early

5. Frontal system abilities (executive

function)

Disproportionately affected Degree of impairment consistent with

other involvement

6. Speed of cognitive processing Slowed early Normal until late in disease

7. Personality Apathetic inert Unconcerned

8. Mood Depressed Euthymic

9. Speech Dysarthric Articulate until late

10. Posture Bowed or extended Upright

11. Co-ordination Impaired Normal until later

12. Motor speed and control Slowed Normal

13. Adventitiois movements Chorea, tremor, tics, dystonia Absent (Alzheimers dementia: some

myoclonus).


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REVERSIBLE AND NON-REVERSIBLE DEMENTIA

Reversible dementia is a term used in themedical literature to describe a dementia that asa specific treatable cause. In the past, dementia

has implied a progressive or irreversible course. E.g. - those arising from inflammatory processes

e.g. encephalopathy caused by systemic lupuserythematosus (SLE) , infections such as syphilis

; or toxic conditions (e.g. Alcohol abuse) thatproduce memory loss and abnormal frontallobe functions


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PRE-SENILEAND SENILEDEMENTIA

PreSenile dementia It resembles that ofsenile dementia except that disorders occurs in

younger age group . the onset of disease occursin people of 40s and 50s and people with thisdisease live an average 11 years after the onset ofdisease.

Senile dementia: It occurs usually after the

age of65yrs. Due to degenerative bring changesas accompanied by a clinical picture of mentaldeterioration. The types of senile dementia arealready mentioned previously.


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Types ofSenile dementia

a)Simple deterioration :- In this patient gradually developsloses of contact with environment poor memory, tendency toreminiscence, intolerance of change, disorientation, restlessness,insomnia, and failure of judgment. This is the commonest psychoticreaction in about 15% of the entire group of senile dementia.

b) Paranoid reaction:- Gradual formation of delusion. He feelsthat his relatives are turned against him and are trying to rob or kill

him c)The presbyophrenic type:- Characterized by jovial mood,marked impairment of memory, restlessness and excitability.

d) Depressed and agitated type:- Severally depressed andagitated, suffers from hypochondrical and Nihilistic delusion.expresses morbid ideas about cancer, syphilis and other diseases.Has marked poverty of ideas.

e) Delirious and contused type: - Shows severe mentalclouding, which make him restless, contused, resistive andincoherent. Completely disoriented to time, place and person.


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Assessment

andmanagement


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Assessment and management

It is important to look for the treatablecauses.

The assessment should also include searchfor treatable, often minor, medicalconditions that are associated ratherprimary causes. Treatment of these

conditions can reduce distress anddisability.


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TREATMENT

Some cases of dementia are regarded as

treatable because the dysfunctional brain tissuemay retain the capacity for recovery if treatmentis timely.

A complete medical history. Physicalexamination , and laboratory tests, includingappropriate brain imaging, should beundertaken as soon as the diagnosis is suspected.

If a patient is suffering from a treatable cause ofdementia, therapy is directed toward treating theunderlying disorder.


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The general treatment approach to patientswith dementia is to provide:

supportive medical care,

emotional support for the patients andtheir families and

pharmacological treatment for specificsymptoms, including disruptive behaviour.


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Symptomatic treatment also includes:

the maintenance of a nutritious diet,

proper exercise,

recreational and activity therapies,

attention to visual and auditory problems,

treatment of infections such as urinarytract infections, decuibtus ulcers, andcardiopulmonary dysfunctions.


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When the diagnosis of vascular dementia is made,risk factors contributing to cerebrovascular

disease should be identified and therapeuticallyaddressed. The factors include:

hypertension

hyperlipidemia

obesity cardiac disease and

diabetes and alcohol dependence.

Patients who smoke should be encouraged to stopsmoking cessation is associated with improvedcerebral perfusion and cognitive functioning.


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Indications for further treatments

Clear indication for hospitalization are:

a history of rapidly deteriorating

symptoms diagnostic uncertainty

failure of usual support system

unmanageable at home advances towards other people

associated medical illness.


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History taking


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History taking

The patients history

More important memories may be maintained indementia because they have been rehearsed often overthe years that they are very fixed. Patient returns to these

memories when the present and recent past are fading.In the earliest stages she will be able to given quite a fullaccount of her life up to recent times, this informationmust be checked for memories become incomplete andtime sequences muddled. These more or less muddled

memories are important in understanding how thepatient reacts to her/his illness.


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The RelativesHistory

From relatives history we can obtain moreinformation about patients previous personality,attitudes, level of activity, interests, socialfunctioning and self care.

It is important to help the relatives separate

recent events, from events that happened beforedementia.

This information will provide clear evidence ofhow much changes has occurred and also helps

in understanding what new problems that familyis having to cope with and so helps to explaintheir reactions.


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Examinations


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The Physical ExaminationA physical examination should be done where indicatedand this is particularly important in the following

circumstances. Where physical symptoms such as weight loss, pain are

present.

Where the patient has a history of potentially relevantphysical disorder like a history of endocrine disorder

Detailed neurological assessment with particularattention to vision and hearing is essential to rule outother neurological problems.Systemic observationshould be made of his behaviour provide a scheme for

assessing memory for general events, past personalevents and recent personal events


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Psychological Testing

a). Wechsler Adult Intelligence Scale (WAIS) :This is a well standardized test providing a profile of

verbal and non-verbal abilities Analysis of sub scores,can provide useful information for diagnosis.

b).Perceptual functions , especiallyspatialrelationship: This test is exemplified by the BentonRevised visual Retention test, which requires the patientto study and reproduce ten designs.

c).NewLearning as a test of memory: a usefulquantitative estimate of memory impairment.

e). Dementia Rating Scale: In this test 2 types ofrating scale is used, the intellectual and behavioural. Thisscale have been over used in diagnosis and limited valuein identifying problems.


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Mental Status Examination

The purpose of the mental stateexamination is to detect abnormal featuresin a patients behaviour and state of mind

at the time of the assessment. If theabnormal features are found thisinformation contributes to the diagnostic

process.


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Mental status examinations

a).General appearance andBehaviour

b).Speech

c).Attitude

d).Mood e). Cognitive function

f).Thought content

g). Judgment

h). Delusions

i).Hallucinations


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Identification of

cause and treatment

Identification of cause and


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Identification of cause and

treatment

Management of hypertension in multi-infract dementia.

Thyroid replacement in hypothyroiddementia .

Shunting in hydrocephalic dementia.

L-Dopa in Parkinsonism.

Removal of toxic agent in toxic dementia.


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Symptomatic Management

Environmental manipulation to reduce stress in day today activities.

Treatment of medical complications

Care of food and hygiene and supportive care for thepatient and family.

Anxiety can be treated with short acting benzodiazepinesin low doses.

Depression can be treated with Trazodone or Miamserinas these agents have low anticholinergic, activity and lowcardiac toxicity. Agents with anticholinergic activity cancause confusion or frank delirium.


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CurrentlyAvailableTreatments

Noortropics: Piracetam, Oxiracetam, Aniracetamderivatives of GABA are postulated to haveneuroprotective effect on CNS against hypoxia.

Ergoloidmesylate: Hydergine is currently used for thenon-specific cognitive impairment.

Aspirin andNSAID: Data suggests that it protectagainst the development of disease due to its anti-inflammatory properties

Estrogen Therapy: Oestrogen therapy inpostmenopausal women might help in the delaying the

development of dementia. Sabeluzole: This substance shown to protect neuronal

cells against gutamate induced and hypoxia inducedinjury and may potentiate the tropic effect of nervegrowth factor. It may improve long term memory of

elderly patient.


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Rivastigmine: Rivastigmine in the dose of 6 to 12mg/Day was given to two groups. One group of patient

was Alzheimers disease with vascular risk factor ashypertension and other group was without riskfactor. After 26 weeks of trial vascular risk factor group

showed significant improvement. Rivastigmine indiffuse Lewy body dementia had shown improvement incognition particularly attention and in psychiatricsymptoms.

Nitrendipine: Elderly people who were suffering from

systolic hypertension when treated with nitrendipine, acalcium channel blocker occurrence of dementia was lessin this group.

Gingko Biloba,Ginseng: It is also helpful indemented patient.


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Psychotherapy

Psychotherapy the specific psychotherapytreatments divided in to 4 broad of range:

Behaviour oriented, Emotion oriented cognitionoriented and stimulation oriented, behaviourapproached can be effective in lessening orabolishing problem behaviour e.g. aggression,incontinence emotion oriented intervention

include supportive psychotherapy reminiscencetherapy sensory integration and stimulatedpresence therapy.


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Types of psychotherapy

Behavior oriented approaches: it can be effective inlessening or abolishing where it occurs, how often itoccurs have to be determined. The next step is anassessment of specific antecedents and consequences,

which will often suggest specific strategies forintervention. Precipitants should be avoided wheneverpossible. Whatever intervention, it is critical to match thelevel of demand on the patients with his or her currentcapacities, to modify the environment in so far as

possible to compensate for deficits and capitalize on thepatients strengths.


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Emotion oriented approaches The interventionincludes supportive psychotherapy, reminiscencetherapy, validation therapy, sensory integration andsimulated presence therapy.

Reminiscence therapy, which acme to stimulate memoryand mood in the context of the patients life history isassociated with modest short lived gain in mood.

Validation therapy, aims to restore self-worth and reducestress by validating emotional ties to the post.

Simulated presence therapy may be helpful in

diminishing problem behavior with social isolation. Supportive psychotherapy may be helpful in mildly

impaired patients to adjust to their illness.


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Cognition oriented approaches: thesetechniques include reality orientation and skillstraining. The aim of these treatments is to

redress cognitive deficits, often in a classroomsetting. There is some evidence of transient

benefit from cognitive redemption and fromskills training but here have been report of

frustration in patients and depression incaregivers associated with the type ofintervention.


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Stimulation orientedapproaches: these treatments includeactivities or recreational therapies (crafts,

gene, and pets) and are therapies (music,dance, art). They provide stimulation andenrichment and thus mobilize the patientsavailable cognitive resources. There are

evidences that, while they are in use, theseinterventions decrease behavioralproblems and improved mood.

h h h l


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Other treatments that may helppatients with dementia

Physiotherapy

It will help to structure their daily activities suchas muscle and joint exercises, breathing

exercises, speech therapy to improv

e bloodcirculation etc. Physiotherapy is helpful forchronic encephalitis, meningitis and generalparesis of insane. It is also helpful to removecontracture of limbs, deformities of extremities

or embolities.; It improves physical health.Appetite, digestion elimination, circulation,muscle tone and body temperature.


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Social Relationship

Dementia patient become isolated fromcommunity. Talking to them and askingordinary questions also help the patient.

More deterioration will take place whenthere is nothing to talk, to think or towork. The social approach plays a greatrole in psychiatric illness. The patient

must learn or relearn how to assumeresponsibility for the welfare of himselfand others for social relationship.


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Daycenters

The day care centers help elder people to meetother people and engage in activities. It isassumed that they will be able to select their

friends and select their activities, will take anactive part in what goes and in most cases, maketheir own way to and from centre. The need forday centers to cater for dementia suffers. Day

care is needed who are the Physically and thementally impaired attending together andinvolving a mice of services.

Th k Y


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Thank YouBE STRONG 4B

Nursing management of geriatric patients with dementia

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