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).

Q:How can the level or degree of the dementia impairment be determined?     

Answer 1

There is no one test to determine if someone has dementia. Doctors diagnose Alzheimer's and other types of dementia based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behavior associated with each type.

Dementia is an overall term for diseases and conditions characterized by a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities. Memory loss is an example. Alzheimer's is the most common cause of dementia.

Dementia is not a single disease; it’s an overall term — like heart disease — that covers a wide range of specific medical conditions, including Alzheimer’s disease. Disorders grouped under the general term “dementia” are caused by abnormal brain changes. These changes trigger a decline in thinking skills, also known as cognitive abilities, severe enough to impair daily life and independent function. They also affect behavior, feelings and relationships.

Many dementias are progressive, meaning symptoms start out slowly and gradually get worse. If you or someone you know is experiencing memory difficulties or other changes in thinking skills, don't ignore them. Professional evaluation may detect a treatable condition. Early diagnosis allows a person to get the maximum benefit from available treatments and provides an opportunity to volunteer for clinical trials or studies. It also provides time to plan for the future.

Alzheimer’s disease typically progresses slowly in three general stages: early, middle and late (sometimes referred to as mild, moderate and severe in a medical context). Since Alzheimer’s affects people in different ways, each person may experience symptoms — or progress through the stages — differently.

Early-stage Alzheimer's (mild)

In the early stage of Alzheimer's, a person may function independently. He or she may still drive, work and be part of social activities. Despite this, the person may feel as if he or she is having memory lapses, such as forgetting familiar words or the location of everyday objects.

Common difficulties include:

• Coming up with the right word or name.
• Remembering names when introduced to new people.
• Having difficulty performing tasks in social or work settings.
• Forgetting material that was just read.
• Losing or misplacing a valuable object.
• Experiencing increased trouble with planning or organizing.

Middle-stage Alzheimer's (moderate)

Middle-stage Alzheimer's is typically the longest stage and can last for many years. As the disease progresses, the person with Alzheimer's will require a greater level of care.

During the middle stage of Alzheimer’s, the dementia symptoms are more pronounced. the person may confuse words, get frustrated or angry, and act in unexpected ways, such as refusing to bathe. Damage to nerve cells in the brain can also make it difficult for the person to express thoughts and perform routine tasks without assistance.

Symptoms, which vary from person to person, may include:

• Being forgetful of events or personal history.
• ​Feeling moody or withdrawn, especially in socially or mentally challenging situations.
• Being unable to recall information about themselves like their address or telephone number, and the high school or college they attended.
• Experiencing confusion about where they are or what day it is.
• Requiring help choosing proper clothing for the season or the occasion.
• Having trouble controlling their bladder and bowels.
• Experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night.
• Showing an increased tendency to wander and become lost.
• Demonstrating personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like hand-wringing or tissue shredding.

In the middle stage, the person living with Alzheimer’s can still participate in daily activities with assistance. It’s important to find out what the person can still do or find ways to simplify tasks. As the need for more intensive care increases, caregivers may want to consider respite care or an adult day center so they can have a temporary break from caregiving while the person living with Alzheimer’s continues to receive care in a safe environment.

Late-stage Alzheimer's (severe)

In the final stage of the disease, dementia symptoms are severe. Individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases, but communicating pain becomes difficult. As memory and cognitive skills continue to worsen, significant personality changes may take place and individuals need extensive care.

At this stage, individuals may:

• Require around-the-clock assistance with daily personal care.
• ​Lose awareness of recent experiences as well as of their surroundings.
• Experience changes in physical abilities, including walking, sitting and, eventually, swallowing
• Have difficulty communicating.
• Become vulnerable to infections, especially pneumonia.

The person living with Alzheimer’s may not be able to initiate engagement as much during the late stage, but he or she can still benefit from interaction in ways that are appropriate, like listening to relaxing music or receiving reassurance through gentle touch. During this stage, caregivers may want to use support services, such as hospice care, which focus on providing comfort and dignity at the end of life. Hospice can be of great benefit to people in the final stages of Alzheimer’s and other dementias and their families.