Want to know more

DEMENTIA
Nursing Standard of Practice Protocol: Recognition and Management of Dementia

Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN

Evidence-Based Content - Updated January 2008

 

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

 

Goal

A. Early recognition of dementing illness.

B. Appropriate management strategies in care of individuals with dementia.

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Overview

The rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. It is imperative that a differential diagnosis be ascertained early in the course of cognitive impairment and that the patient is closely monitored for coexisting morbidities. Nurses have a central role in assessment and management of individuals with progressive dementia.

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Background

A. Definitions/Distinctions

1. Dementia is a clinical syndrome of cognitive deficits that involves both memory impairments and a disturbance in at least one other area of cognition (e.g., aphasia, apraxia, agnosia) and disturbance in executive functioning. 1

2. In addition to disruptions in cognition, dementias are commonly associated with changes in function and behavior.

3. The most common forms of progressive dementia are Alzheimer's disease, vascular dementia, and dementia with Lewy bodies; the pathophysiology for each is poorly understood.

4. Differential diagnosis of dementing conditions is complicated by the fact that concurrent disease states (i.e., co-morbidities) often coexist.

B. Prevalence

1. Dementia affects about 5% of individuals 65 and older. 2

2. Four to five million Americans have Alzheimer's disease (AD) 3

3. 13.2 million are projected to have AD by 2050. 3

4. Global prevalence of dementia is about 24.3 million, with 6 million new cases every year. 4

C. Risk Factors

1. Advanced age

2. Mild cognitive impairment

3. Cardiovascular disease

4. Genetics: family history of dementia, Parkinson's disease, cardiovascular disease, stroke, presence of ApoE4 allele on chromosome 19

5. Environment: head injury, alcohol abuse

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Parameters of Assessment

No formal recommendations for cognitive screening are indicated in asymptomatic individuals. Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia and dementia-like presentation in early stages. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.

A. Cognitive Parameters

1. Orientation: person, place, time

2. Memory: ability to register, retain, recall information

3. Attention: ability to attend and concentrate on stimuli

4. Thinking: ability to organize and communicate ideas

5. Language: ability to receive and express a message

6. Praxis: ability to direct and coordinate movements

7. Executive function: ability to abstract, plan, sequence, and use feedback to guide performance

B. Mental Status Screening Tools

1. Folstein Mini-Mental State Examination: 5 The most commonly used test to assess serial cognitive change. On average, the MMSE declines 3 points per year in those with AD. 6 It is composed of items assessing orientation, attention, concentration, memory, language, and construction ability. Age, education, cultural background, and perceptual and physical abilities can affect performance. The MMSE might not detect mild cognitive loss and, as well, it is not diagnostic of decision-making capacity. 7

2. Clock Drawing Test (CDT):8 a useful measure of cognitive function that correlates with executive-control functions (i.e., the cognitive process necessary to plan and carry out goal-directed behaviors). The patient is asked to draw a clock free-hand, put in all the numbers, and set a time asked for by the examiner. Physical ability and dexterity can influence performance.

3. Mini-Cognitive (Mini-Cog) 9 combines the Clock Drawing Test with the three-word recall. The patient is asked to remember three unrelated words and later is asked to recall the three words. This clinically useful tool, rapidly administered, has a high level of sensitivity and specificity and less bias than some other instruments (e.g., the MMSE). 10

When the diagnosis remains unclear, the patient may be referred for more extensive screening and neuropsychological testing, which might provide more direction and support for the patient and the caregivers.

C. Functional Assessment

1. Tests that assess functional limitations such as the Functional Activities Questionnaire (FAQ)11 can detect dementia with sensitivity and specificity comparable to mental-status testing. They are also useful in monitoring the progression of functional decline.

2. The severity of disease progression in dementia can be demonstrated by performance decline in ADL and IADL tasks and is closely correlated with mental-status scores. 12

D. Behavioral Assessment

1. Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.

2. Evaluate for depression because it commonly coexists in individuals with dementia. 13 Symptoms and signs may include the presence of neurovegetative signs (e.g., hypersomnia, insomnia, increased or decreased appetite, decreased energy, weight loss or gain, psychomotor agitation or slowing) or mood changes (e.g., depressed mood, feelings of worthlessness or helplessness, suicidal ideation). Determine if there is a diminished level of interest in life. Is there a lack of motivation, decreased initiation, or a poor ability to sustain effort?

E. Physical Assessment

1. A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.

2. A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal, and nutritional products taken is done to determine the potential impact on cognitive status.

3. Laboratory tests are valuable in differentiating irreversible from reversible forms of dementia. Structural neuroimaging with noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scans are appropriate in the routine initial evaluation of patients with dementia.

F. Caregiver/Environment The caregiver of the patient with dementia often has as many needs as the patient with dementia; therefore, a detailed assessment of the caregiver and the caregiving environment is essential.

1. Elicit the caregiver perspective of patient function and the level of support provided.

2. Evaluate the impact that the patient's cognitive impairment and problem behaviors have on the caregiver (mastery, satisfaction, and burden). Two useful tools include the Zarit Burden Interview (ZBI) 14 and the Caregiver Strain Index (CSI) Tool CSI. 15 (For CSI see Try This Issue 14 - Caregiver Strain Index (CSI)).

3. Evaluate the caregiver experience and patient–caregiver relationship. The caregiving experience is a stressful one and the potential for elder mistreatment and caregiver illness exists.

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Nursing Care Strategies

Based on evidence provided under the Interventions and Care Strategies in this chapter; specifically, use of the PLST that provides a framework for the nursing care of individuals with dementia. 16

A. Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.

B. Provide appropriate cognitive-enhancement techniques and social engagement.

C. Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.

D. Avoid the use of physical and pharmacologic restraints.

E. Maximize functional capacity: Maintain mobility and encourage independence as long as possible, provide graded assistance as needed with ADLs and IADLs, provide scheduled toileting and prompted voiding to reduce urinary incontinence, encourage an exercise routine that expends energy and promotes fatigue at bedtime, establish bedtime routine and rituals.

F. Address behavioral issues: Identify environmental triggers, medical conditions, caregiver–patient conflict that may be causing the behavior, define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches, provide reassurance; refer to appropriate mental-health care professionals as indicated.

G. Ensure a therapeutic and safe environment: Provide an environment that is modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion, and understimulation that can cause sensory deprivation and withdrawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, wander guard; eliminate any environmental hazards and modify the environment to enhance safety; provide environmental cues or sensory aides that facilitate cognition; maintain consistency in caregivers and approaches.

H. Encourage and support advance-care planning: Explain trajectory of progressive dementia, treatment options, and advance directives.

I. Provide appropriate end-of-life care in terminal phase: Provide comfort measures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (tube feeding, antibiotic therapy).

J. Provide caregiver education and support: Respect family systems/dynamics and avoid making judgments, encourage open dialogue, emphasize the patient’s residual strengths, provide access to experienced professionals, teach caregivers the skills of caregiving.

K. Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (i.e., Alzheimer’s Association, Respite Care, Specialized Long Term Care) and informal (i.e., churches, neighbors, extended family/friends) support systems.

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Evaluation/Expected Outcomes

A. Patient Outcomes: The patient remains as independent and functional in the environment of choice for as long as possible, the co-morbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at end of life are minimized or controlled adequately.

B. Caregiver Outcomes (lay and professional): Caregivers demonstrate effective caregiving skills; verbalize satisfaction with caregiving; report minimal caregiver burden; are familiar with, have access to, and utilize available resources.

C. Institutional Outcomes: The institution reflects a safe and enabling environment for delivering care to individuals with progressive dementia; the quality improvement plan addresses high-risk problem-prone areas for individuals with Dementia, such as falls and the use of restraints.

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Follow-up to Monitor Condition

A. Follow-up appointments are regularly scheduled; frequency depends on the patient’s physical, mental, and emotional status and caregiver needs.

B. Determine the continued efficacy of pharmacological/nonpharmacological approaches to the care plan and modify as appropriate.

C. Identify and treat any underlying or contributing conditions.

D. Community resources for education and support are accessed and utilized by the patient and/or caregivers.

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Relevant Practice Guidelines

A. American Academy of Neurology: Detection of Dementia, Diagnosis of Dementia, Management of Dementia, and Encounter Kit for Dementia: http://www.aan.com/professionals/practice/guideline/

B. American Geriatrics Society: Clinical Recommendations for Feeding Tube Placement in Elderly Patients with Advanced Dementia: http://www.americangeriatrics.org/education/cp_index.shtml

C. American Association of Geriatric Psychiatry: Position Statement: Principles of Care for Patients with Dementia Resulting from Alzheimer’s Disease: http://www.aagponline.org/prof/position_caredmnalz.asp

D. Alzheimer’s Foundation of America (AFA): Excellence in Care: http://www.alzfdn.org

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For Definition of Levels of Quantitative Evidence Click Here

Reprinted with permission from Springer Publishing Company. Fletcher, K. 2008. Dementia. In E. Capezuti, D. Zwicker, M. Mezey, & T. Fulmer (Eds.) Evidence-Based Geriatric Nursing Protocols for Best Practice (3rd ed), New York: Springer Publishing Company, Inc. ed.).

References

1. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th ed.). Evidence Level VI: Expert Opinion.

2. Richie, K., & Lovestone, S. (2002). The dementias. Lancet, 360(9347), 1767–1769. Evidence Level VI: Expert Opinion.

3. Hebert, L. E., Scheer, P. A., Bienias, J. L., Bennett, D. A., & Evans, D. A. (2003). Alzheimer’s disease in the U.S. population: Prevalence estimates using the 2000 census. Archives of Neurology, 60, 1119–1122. Evidence Level IV: Nonexperimental Study.

4. Ferri, C. P., Prince, M., Brayne, C., Brodaty, H., Fratiglioni, L., & Ganguli, M., et al. (2005). Global prevalence of dementia: A Delphi consensus study. Lancet, 366(9503), 2112–2117. Evidence Level IV: Nonexperimental Study.

5. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). Mini-mental state. Journal of Psychiatric Research, 12, 189–198. Evidence Level IV: Nonexperimental Study.

6. Han, L., Cole, M., Bellavance, F., McCusker, J., & Primeau, F. (2000). Tracking cognitive decline in Alzheimer’s disease using the mini-mental state examination: A meta-analysis. International Psychogeriatrics, 12 (2), 231-247. Level I: Systematic review.

7. Parker, C., & Philp, I. (2004). Screening for cognitive impairment among older people in Black and minority ethnic groups. Age and Aging, 33, 447–452. Evidence Level VI: Expert Opinion.

8. Royall, D. R., Mulroy, A. R., Chiodo, L. K., & Polk, M. J. (1999). Clock drawing is sensitive to executive control: A comparison of six methods. Journal of Gerontology & Psychological Science and Social Science, 54B(5), 328–333. Evidence Level IV: Nonexperimental Study.

9. Borson, S., Scanlan, J., Brush, M ., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multilingual elderly. International Journal of Geriatric Psychiatry, 15(11), 1021–1027. Evidence Level IV: Nonexperimental Study.

10. Borson, S., Scanlan, J. M., Chen, P., & Ganguli, M. (2003). The Mini-Cog as a screen for dementia: Validation in a population-based sample. Journal of the American Geriatrics Society, 51, 1451–1454. Evidence Level IV: Nonexperimental Study.

11. Pfeffer, R. I., Kurosaki, T. T., Harrah, C. H., Chance, J.M., & Filos, S. (1982). Measurementof functional activities of older adults in the community. Journal of Gerontology, 37(3), 323–329. Evidence Level IV: Nonexperimental Study.

12. Galasko, D., Bennett, D. A., Sano, M., Ernesto, C., Thomas, R., Grundman, M., et al. (1997). An inventory to assess activities of daily living for clinical trials in Alzheimer’s disease: The Alzheimer’s Disease Cooperative Study. Alzheimer’s Disease and Associative Disorders, 11 (Suppl. 2), S33–S39. Evidence Level IV: Nonexperimental Study.

13. Zubenko, G. S., Zubenko, W. N., McPherson, S., Spoor, E., Marin, D. B., Farlow, M. R., et al. (2003). A collaborative study of the emergence and clinical features of the major depressive syndrome of Alzheimer’s disease. American Journal of Psychiatry, 160(5), 857–866. Evidence Level IV: Nonexperimental Study.

14. Bedard, M., Molloy, D. W., Squire, I., Dubois, S., Lever, J. A., & O’Donnell, M. (2001). The Zarit Burden Interview: A new short version and screening version. Gerontologist, 41(5), 652–657. Evidence Level IV: Nonexperimental Study.

15. Robinson, B. (1983). Validation of a Caregiver Strain Index. Journal of Gerontology 38, 344-348. Level IV: Non-experimental.

16. Smith, M., Hall, G. R., Gerdner, L., & Buckwalter, K. C. (2006). Application of the progressively lowered stress threshold model across the continuum of care. Nursing Clinics of North America, 41(1), 57–81. Evidence Level V: Case Study.

Last updated - January 2008

 
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