1. Confusion and Dementia
Chapter 46
Confusion and Dementia
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2. Changes in the Brain
Changes in the brain and nervous system occur with aging and diseases.
Cognitive function and quality of life may be affected.
Cognitive function involves:
Memory
Thinking
Reasoning
Ability to understand
Judgment
Behavior
Cognitive relates to knowledge.
Review the contents of Box 46-1 on p. 741 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

3. Confusion Confusion has many causes. The person may be:
Diseases and infections
Hearing and vision loss
Drug side effects
Brain injury
Age-related changes resulting in reduced blood supply to the brain
The person may be:
Angry
Restless
Depressed
Irritable
With aging, blood supply to the brain is reduced: personality and mental changes can result; memory and the ability to make good judgments are lost; some people gradually lose the ability to perform daily activities; behavior changes are common.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. Confusion (cont’d) Acute confusion (delirium) occurs suddenly.
It is usually temporary.
Causes include infection, drugs, illness, surgery, and injury.
Treatment is aimed at the cause.
Confusion from physical changes cannot be cured.
Some measures help to improve function.
Review the contents of Box 46-2 on p. 741 in the Textbook.
You must meet the person’s basic needs.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5. Dementia
Dementia is the loss of cognitive function that interferes with routine personal, social, and occupational activities.
Dementia is a group of symptoms that may occur with certain diseases or conditions.
Dementia is not a normal part of aging.
Most older people do not have dementia.
The person with dementia may have changes in personality, mood, or behavior.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Dementia (cont’d) Early warning signs of dementia include:
Recent memory loss that affects job skills
Problems with common tasks
Problems with language; forgetting simple words
Getting lost in familiar places
Misplacing things and putting things in odd places
Personality changes
Poor or decreased judgment
Loss of interest in life
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. Dementia (cont’d)
If brain changes have not occurred, some dementias can be reversed.
Treatable causes include:
Drugs and alcohol
Delirium and depression
Tumors
Heart, lung, and blood vessel problems
Head injuries
Infection
Vision and hearing problems
When the cause is removed, so are the signs and symptoms.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8. Dementia (cont’d)
Permanent dementias result from changes in the brain. They have no cure.
Alzheimer’s disease is the most common type of permanent dementia.
Pseudodementia means false dementia.
The person has signs and symptoms of dementia.
There are no changes in the brain.
This can occur with delirium and depression.
Both can be mistaken for dementia.
Review the Causes of Permanent Dementia listed in Box 46-3 on p. 742 in the Textbook.
With permanent dementias, function declines over time.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

9. Dementia (cont’d)
Delirium is a state of sudden, severe confusion and rapid changes in brain function.
Usually temporary and reversible
It occurs with physical or mental illness.
It often lasts for about one week.
Causes include:
Acute or chronic illness
Surgery
Drug or alcohol abuse
Infections
Delirium is an emergency.
It signals physical illness.
The cause must be found and treated.
Although delirium has a short course, it may take several weeks for normal mental function to return.
See Box 46-4 on p. 742 for signs and symptoms.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

10. Dementia (cont’d)
Depression is the most common mental health problem in older persons.
It is often overlooked.
Depression, aging, and some drug side effects have similar signs and symptoms.
Mild cognitive impairment (MCI) is a type of memory change.
The person with MCI has problems with memory, language, and other mental functions. However, the problems do not interfere with daily life.
The person with MCI is at risk for Alzheimer’s disease.
Review the signs and symptoms of depression in older persons listed on p. 732 in Chapter 45 in the Textbook.
The person or others may notice the problems associated with MCI.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

11. Alzheimer’s Disease Alzheimer’s disease (AD) is a brain disease.
Many nerve cells that control intellectual and social function are damaged and die.
The following functions are affected:
Memory
Thinking
Reasoning
Judgment
Language
Behavior
Mood
Personality
The person has problems with work and everyday functions.
Problems with family and social relationships occur.
There is a slow, steady decline in memory and mental function.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

12. Alzheimer’s Disease (cont’d)
AD onset is gradual.
Usually, symptoms first appear after age 60.
Nearly half of the persons age 85 and older have AD.
More women than men are affected.
The cause is unknown.
AD is not a normal part of aging.
A family history of AD increases a person’s risk of developing the disease.
The classic sign of AD is gradual loss of short-term memory.
At first, the only symptom may be forgetfulness.
The person with AD can live 3 to 4 years or as long as 10 or more years.
Women with AD live longer than men.
Review the contents of Box 46-5 on p. 743 in the Textbook for the Signs of Alzheimer’s Disease.
Review Box 46-6 on p. 743 in the Textbook for the differences between AD and normal age-related changes.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Alzheimer's Disease (AD)
What is Alzheimer's Disease?

14. Alzheimer’s Disease (cont’d)
Stages of AD
Signs and symptoms become more severe as the disease progresses.
The disease ends in death.
AD is often described in terms of 3 stages: mild, moderate, and severe.
The Alzheimer’s Association describes 7 stages:
Stage 1 - No impairment
Stage 2 - Very mild cognitive decline
Stage 3 - Mild cognitive decline
Stage 4 - Moderate cognitive decline
Stage 5 - Moderately severe cognitive decline
Stage 6 - Severe cognitive decline
Stage 7 - Very severe cognitive decline
Review the Stages of Alzheimer’s Disease in Box 46-7 on p. 744 in the Textbook.
During the final stage of the disease, the person cannot respond to his or her setting, speak, or control movement.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

15. Alzheimer’s Disease (cont’d)
Alzheimer’s disease changes how a person behaves and acts.
Health-related issues can make the problems worse. Examples include illness, infection, drugs, lack of sleep, constipation, hunger, thirst, poor vision or hearing, alcohol, and caffeine.
These changes are common: getting upset, worried, or angry more easily; acting depressed; losing interest in things; hiding things; believing other people are hiding things; pacing a lot of the time; wandering; sundowning; hallucinations; delusions; catastrophic reactions; agitation and restlessness; aggression and combativeness; screaming; problems with intimacy and sexuality; repetitive behaviors and communication problems.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

16. Alzheimer’s Disease (cont’d)
Problems in the person’s setting may also make changes in behavior worse. According to the National Institute on Aging (NIA), they include:
A strange setting
Too much noise
Stepping from one type of flooring to another
Not understanding signs
Mirrors
Review the Promoting Safety and Comfort: Behaviors and Problems Box on p. 745 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

17. Care of Persons with AD and Other Dementias
Usually, the person is cared for at home until symptoms are severe.
Adult day care may help.
Often, assisted living or nursing center care is required.
Sometimes, hospital care is needed for other illnesses.
You may care for persons with AD or other dementias.
The person and family need your support and understanding.
People with AD do not choose to be forgetful, incontinent, agitated, or rude. They do not choose to have other behaviors, signs, and symptoms of the disease. The disease causes the behaviors.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

18. Care of Persons with AD and Other Dementias (cont’d)
Currently, AD has no cure.
Symptoms worsen over many years.
The rate varies from person to person.
The following needs must be met:
Safety
Hygiene
Nutrition and fluids
Elimination
Activity
Comfort and sleep
Over time, persons with AD depend on others for care.
The person’s care plan will include many of the measures listed in Box 46-9 on pp in the Textbook.
Comfort and safety are important.
Good skin care and alignment prevent skin breakdown and contractures.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

19. Care of Persons with AD and Other Dementias (cont’d)
You must treat these persons with dignity and respect.
They have the same rights as persons who are alert and active.
Talk to them in a calm voice.
Always explain what you are going to do.
Range-of-motion exercises and touch are important therapies.
The person may need hospice care as death nears.
Massage, soothing touch, music, and aromatherapy are comforting and relaxing.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

20. Care of Persons with AD and Other Dementias (cont’d)
The person can have other health problems and injuries.
The person may not be aware of signs and symptoms.
The person cannot fully tend to self-care.
Infection is a risk. It can occur from poor hygiene.
Inactivity and immobility can cause pneumonia and pressure ulcers.
The person needs to feel useful, worthwhile, and active.
Therapies and activities focus on the person’s strengths and past successes.
Carefully observe the person. Report any change in the person’s usual behavior to the nurse.
Feeling useful, worthwhile, and active promotes self-esteem. Therapists work with one person, a small group, or a large group. Supervised activities meet the person’s needs and cognitive abilities. Activities are based on what the person enjoys and can do.
Review Focus on Long-Term Care and Home Care: Care of Persons with AD and Other Dementias Box on p. 753 in the Textbook.
Review Teamwork and Time Management: Care of Persons with AD and Other Dementias Box on p. 753 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

21. Activities to Do with AD Residents

22. Care of Persons with AD and Other Dementias (cont’d)
The family
Health care is sought when the family cannot deal with the situation or meet the person’s needs.
Home health care may help for a while.
Adult day care is an option.
Long-term care is needed when:
Family members cannot meet the person’s needs.
The person no longer knows the caregiver.
Family members have health problems.
Money problems occur.
The person’s behavior presents dangers to self and others.
Diagnostic tests, doctor’s visits, drugs, and home care are costly, so is long-term care.
The person’s medical care can drain family finances.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

23. Care of Persons with AD and Other Dementias (cont’d)
Home care and nursing center care are stressful.
The family has special needs.
Physical
Emotional
Social
Financial
Adult children are in the sandwich generation.
They are caught between their own children needing attention and an ill parent needing care.
Asking family and friends for help is important.
However, asking for help is hard for some people.
Caring for two families is stressful. Often, adult children have jobs, too.
Caregivers can suffer from anger, anxiety, guilt, depression, and sleeplessness. They can develop health problems.
According to the NIA, families feel: they should do everything themselves; it is wrong to leave the person with someone else; no one will help if they ask; they don’t have money to pay someone to help or watch the person for 1 or 2 hours.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

24. Care of Persons with AD and Other Dementias (cont’d)
Caregivers need much support and encouragement.
AD support groups are helpful.
Support groups share coping and caregiving ideas.
The family often feels hopeless.
No matter what is done, the person gets worse.
Anger and resentment may result.
Guilt feelings are common.
The family is an important part of the health team.
They help plan care whenever possible.
The nurse and support group help the family learn how to give needed care.
AD support groups are sponsored by hospitals, nursing centers, and the Alzheimer’s Association.
Members of support groups share their feelings, anger, frustration, guilt, and other emotions.
The family knows that the person did not choose the disease and its signs, symptoms, and behaviors. Sometimes, behaviors are embarrassing. The family may be upset and angry that the loved one cannot show love or affection.
Some family members take part in unit activities. For many persons, family members provide comfort. They also need support and understanding from the health team.
Review the Focus on Long-Term Care and Home Care: The Family Box on p. 754 in the Textbook.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

25. AD Video
Alzheimer's Disease

26. Caregiver Guide
National Institute of Aging
Helpguide

27. Helpful Ideas
A large calendar can help confused persons.

28. Signs give cues to persons with dementia.

29. A slide lock is at the top of the door.

30. Walk outside with the person who wanders
Walk outside with the person who wanders. Then guide the person back inside after a few minutes.

31. Walk outside with the person who wanders
Walk outside with the person who wanders. Then guide the person back inside after a few minutes.

32. Use touch to calm the person.

33. The person with AD is offered simple clothing choices.

34. Care of Persons with AD and Other Dementias (cont’d)
Validation therapy may be part of the person’s care plan.
The health team decides if validation therapy might help a person.
If the therapy is used in your agency, you will receive the training needed to use it correctly.
Validation therapy is based on many principles. A person may return to the past to resolve issues and emotions. With validation therapy, caregivers need to listen and provide empathy. Attempts are not made to correct the person’s thoughts or bring the person back to reality.
Review the examples of situations using validation therapy provided on p. 754 in the Textbook.
Proper use of validation therapy requires special training.
Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.