Question

Scenario

You are the nurse working triage in the emergency department (ED). This afternoon a woman brings in her father, ALI, a 72-year-old who is a retired doctor. The daughter reports that over the past several months she has noticed her father has progressively had problems with his mental capacity. These changes have developed gradually but seem to be getting worse. At times he is alert, and at other times he seems disoriented, depressed, and tearful. He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. He had difficulty finding objects in the kitchen and at times forgets where his room is.

This morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his coffee, and he seems to be getting more agitated. ALI reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends.

A review of his past medical history (PMH) is significant for hypercholesterolemia and coronary artery disease (CAD). He had a myocardial infarction (MI) 5 years ago. ALI’s vital signs (VS) today are all within normal limits (WNL).

Case study discussion

Please answer the following questions.

1. Discuss three cognitive changes seen in several elderly patients?             

2. You know that age-related changes in the elderly may influence cognitive functioning. Name and discuss two.

3. You understand that other disorders may have presentations similar to dementia. Name one and discuss it

4. Discuss four patient behaviors you would associate with depression.

5. What patients’ behavior would you associate with delirium? Discuss three.

6. What are the behaviors associated with dementia? Identify three.

7. You know that there are four main types of dementia that result in cognitive changes. List two types.

8. How can the level or degree of the dementia impairment be determined?

9. How do you manage a patient who is showing some signs of agitation and aggression? Discuss two skills.

10. Discuss four nursing interventions for patients who are experiencing disturbed thought processes, impaired memory, and disturbed sensory perceptions.

Answer 1

Question number 1.

Three cognitive changes seen in several elderly patients associated with aging are:

Slowed processing speed: It refers to the speed of information processing and generation of a motor response. Slowed processing speed negatively affects performance resulting in taking more than normal time to respond to a stimulus, difficulty in taking quick judgment in emergencies or while driving.

Decreased attention: Attention refers to the ability to focus or concentrate on a stimulus. It is of two types of selective attention that is the ability to focus on selective aspects and filtering of irrelevant information for example communicating with someone in noisy surroundings and another is divided attention that is the ability to focus on multiple tasks simultaneously. Ability to ignore irrelevant information is reduced with age, resulting in confusion, calculation mistakes, difficulty in the sequential arrangement of things like following the steps of a recipe, keeping track of monthly bills, etc. There is more difficulty in performing tasks that require dividing or switching attention between multiple tasks.

Changes in memory: One of the most common cognitive impairment with age is seen in memory. Long term memories like episodic memory that is free recall of people or places without a clue is delayed, difficulty in recalling the source of information, repeating the same questions, or the same stories again and again. There is also forgetfulness about the actions to be taken in the future like forgetting to take medications While the semantic memory (ability to remember facts) and procedural memory like the ability to sing a familiar song, or doing a common task like tying shoelaces are preserved. There is significant deficit in working memory. Due to difficulty in reorganization and integration of memory tasks like decision making and problem solving are affected.

Question number : 2

Age related changes that may affect cognitive functioning in elderly are:

Dementia:

Dementia is a syndrome characterized by acquired, progressive deterioration of cognitive function, intellect behaviour and personality. It affects 10% of individuals over 65 years of age. Incidence of age-related dementia doubles in frequency every five years after age of 65 years and is about 50 % in those above 85 years of age.

Dementia is not a disease but a term used to describe a cluster of symptoms including: forgetfulness, progressive difficulty in doing familiar tasks, confusion, poor judgment, decline in intellectual functioning.

Risk factors for dementia are age (above 65), sex (male), overweight, use of drug, smoking and alcohol, high blood pressure, cholesterol, heart diseases, diabetes, high blood sugar, depression, stress, head injury, tumour, HIV infection, some immunological disorders poor education, low physical activity, poor nutrition, Alzheimer’s disease, vascular dementia (resulting from strokes and transient ischemic attacks), Parkinson’s disease, hydrocephalus, dementia with Lewy bodies, and other causes.

Symptoms include clouded sensorium, delirium, forgetfulness, aphasia, apraxia, poor judgment, and catastrophic reactions.

Management depends on identification of cause and its appropriate treatment.

Alzheimer’s disease:

Alzheimer's disease is a chronic, irreversible neurodegenerative disorder and the most common type of dementia accounting for 60 to 80 percent of all dementia cases. It usually starts in late middle age or in old age (common in 65 years or more) due to the degeneration of brain neurons especially in the cerebral cortex and amyloid deposition resulting in progressive loss of memory, impaired thinking, disorientation, and changes in personality and mood.

However it is not the normal part of aging and gets worse over time.

The exact cause of Alzheimer's disease is not yet fully understood. Alzheimer's disease is thought to be caused by the abnormal build-up of proteins (amyloid), which form plaques in and around brain cells.

Several factors are associated with Alzheimer's disease: increasing age, family history, gender (more common in women), head injuries, chronic hypertension and high cholesterol, heart disease, diabetes, stroke, smoking and drinking, exposure to heavy metals, industrial or other toxins, use of cholesterol-lowering drugs (statin).

Alzheimer’s disease typically progresses slowly in three general stages: early, middle and late.

Person experiences memory loss, difficulty in performing familiar tasks, problems with language, disorientation to time and place, poor or decreased judgment, problems with abstract thinking, misplacing things, changes in mood or behaviour, changes in personality, loss of imitativeness.

The disease may cause a person to become confused, get lost in familiar places, misplace things or difficulty in recalling, trouble with language, personality changes and unexplained mood swings.

There is no cure for Alzheimer's disease. Aim of treatment is symptom improvement and enhance the quality of life and daily activities and behaviour.

There is no way to stop the underlying death of brain cells. But pharmacological and nonpharmacological treatments may help with both cognitive and behavioural symptoms

Intervention include Acetylcholinesterase inhibitors like (Donepezil, Rivastigmine, Galantamine), N-Methyl d-aspartate Receptor Antagonists, anxiolytics, antipsychotics and antidepressants

Since Alzheimer's has no cure and it gradually renders people incapable of tending for their own needs, caregiving essentially is the treatment and must be carefully managed over the course of the disease

As there is no known identifiable cause prevention is not possible.