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

1. Three cognitive changes seen in elderly patients are :

• Processing speed : reduced speed of information processing and response.
• Decreased memory and decreased  retention of information.
• Sensory and perpetual changes : decrement in visual and auditory acuity and other perpetual changes.

2. Two changes that lead to cognitive problems are

• Brain structural changes : changes in the very structural organisation can lead to such results. It includes phenomenon such as grey matter shrinkage and white matter de- myelination.
• Neurobiological changes : Neurological changes such as neural atrophy and altered neurotransmitter and synaptic activity can lead to reduced cognitive functions. Neural atrophy can lead to slower responses and alterations in neurotransmitter functions can lead to depression, reduced motor functions etc.

3. Another disease that mimics dementia is delirium. It is also affected by age and causes memory loss. But it is reversible, moderate in nature and can be treated. It has a sudden beginning point and short term confusion and changes in cognition. It can be caused by factors such infectious, metabolic, trauma etc.

4. Patient behaviour associated with depression:

• Agitation and restlessness: people find it difficult to stay calm and often become angry and irritated with small things.
• Lethargy: most people with depression often have reduced motivation to even do day to day activities.
• Procrastination : pessimism and procrastination are very common among patients with depression. They do not feel like putting effort to do things that could help them.
• Irregular diet and sleeping patterns : patients tend to adopt unhealthy ways of eating ( eat too much or do not eat at all ) and they do not maintain a normal healthy sleeping routine.

5. Three patient behaviour associated with delirium:

• Decreased activities of daily living and memory loss.
• Emotional changes such as agitation, depression, dysphoria.
• Mood changes due to direct effect of confusion all state on the limbic system and it's regulation of emotions.

6. Behaviors associated with dementia

• Slower reaction time
• Reluctance to try new things
• mood swings
• easily provoked over little things
• socially inappropriate behaviour
• poor management in self care.

7. Types of dementia include

• Alzheimer's disease
• vascular dementia
• dementia with Lewy bodies
• Frontotemporal dementia
• Parkinson's disease

8. Degree of dementia can be obtained by CDR ( Clinical dementia rating )

• 0- normal
• 0.5 - very mild dementia
• 1- mild
• 2-moderate
• 3- severe

Stages of dementia are :

• 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

9. Management of agitation

• Creating a calm environment and by removing stressors. Limiting caffeine intake.
• Avoid environmental factors triggering the agitation.
• Monitoring of personal comfort and simplifying tasks and routines.

10. Nursing interventions:

• Establish trust and effective communication.
• Discuss underlying feeling of stressful situations and how to deal with it.
• Assist the patient in identifying conflicts and help in finding solutions and follow up on carrying out the resolution.
• Ensure calm and peaceful environment to help the patient regain control on thought process.