Dementia

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.

BACKGROUND

A.  Definitions/distinctions

  1. Dementia (also referred to as a major neurocognitive disorder) is a clinical syndrome of disruptions in cognition.
  2. In addition to disruptions in cognition, dementias are commonly associated with changes in function, mood, and behavior.
  3. The most common forms of progressive dementia are AD, VaD, DLB, and FTD; the pathophysiology for each is poorly understood.
  4. Differential diagnosis of dementing conditions is complicated by the fact that concurrent disease states (i.e., comorbidities) often coexist.

B.  Prevalence

  1. Dementia affects about 11% of individuals aged 65 years and older.
  2. More than 5.8 million individuals in the United States have AD, with the number projected at about 14 million cases by 2050.
  3. Global prevalence of dementia is about 50 million, and is projected to reach 135.5 million by 2050.

C.  Risk factors

  1. Advanced age
  2. MCI
  3. Cardiovascular disease
  4. Genetics: family history of dementia, PDD, cardiovascular disease, stroke, presence of ApoE4 allele on chromosome 19
  5. Environment: head injury, alcohol abuse

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. SLUMS and MoCA are commonly used tools.
  2. CDT is a useful measure of cognitive function that correlates with executive control functions.
  3. Mini-Cog combines the CDT with the three-word recall.

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 FAQ and the FAST, can detect dementia. 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.

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. The GDS is a good screening tool.

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. Two laboratory tests specifically recommended in the initial evaluation are thyroid function and B12. Structural neuroimaging with noncontrast CT or MRI scans is appropriate in the routine initial evaluation of patients with dementia.

F.   Caregiver/environment

  1. The caregiver of the patient with dementia often has as many needs as the patient with dementia, so a detailed assessment of the caregiver and the caregiving environment is essential.
    • Elicit the caregiver perspective of patient function and the level of support provided.
    • 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 ZBI and the CSI tools.
    • Evaluate the caregiver experience and patient/caregiver relationship.

NURSING CARE STRATEGIES

A.  The PLST framework provides a framework for the nursing care of individuals with dementia.

  1. Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.
  2. Provide appropriate cognitive-enhancement techniques and social engagement.
  3. Assure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
  4. Avoid the use of physical and pharmacological restraints.
  5. Maximize functional capacity: Maintain mobility and encourage independence as long as possible, provide graded assistance as needed with ADL and IADL, provide scheduled toileting and prompted voiding to reduce urinary incontinence, encourage an exercise routine that expends energy and promotes fatigue at bedtime, and establish bedtime routine and rituals.
  6. 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; and refer to appropriate mental healthcare professionals as indicated.
  7. Assure a therapeutic and safe environment: Provide an environment that is modestly stimulating, avoiding overstimulation, which can cause agitation and increase confusion, and understimulation, which can cause sensory deprivation and withdrawal. Eliminate any environmental hazards and modify the environment to enhance safety. Provide environmental cues or sensory aids that facilitate cognition, and maintain consistency in caregivers and approaches. Psychosocial interventions and cultural arts therapy in dementia may prove beneficial.
  8. Encourage and support advance care planning: Explain the trajectory of progressive dementia, treatment options, and advance directives.
  9. Provide appropriate EOL care in the terminal phase: provide comfort measures, including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (tube feeding, antibiotic therapy).
  10. 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; and teach caregivers the skills of caregiving.
  11. 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.

EVALUATION/EXPECTED OUTCOMES

A.  Patient outcomes: The patient remains independent and functional in the environment of choice for as long as possible, the comorbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at EOL are minimized or controlled adequately.

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

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 used by the patient and/or caregivers.

RELEVANT PRACTICE GUIDELINES/RESOURCES

A.  American Academy of Neurology. (2001). Dementia. Retrieved from https://www.aan.com/Guidelines/home/ByTopic?topicId=15

B.  American Association of Geriatric Psychiatry. (2006). Position statement: Principles of care for patients with dementia resulting from Alzheimer disease. Retrieved from www.aagponline.org/index.php?src=news&submenu=Tools_Resources&srctype=detail&category=Position%20Statement&refno=35

C.  Alzheimer’s Foundation of America: Excellence in Care. (n.d.). Retrieved from www.alzfdn.org

D.  American Geriatrics Society: geriatricscareonline.org

E.  Geriatric Advance Practice Nurse Association. (n.d.). Retrieved from https://www.gapna.org/resources/toolkits/toolkit-gerontology-resources-aprn-preceptors-and-students

F.   The Society for Post-acute and Long-term Care Medicine (formerly, the American Medical Directors Association). Retrieved from https://paltc.org

ABBREVIATIONS

AD              Alzheimer’s disease

ADL            Activities of daily living

BPSD          Behavioral and psychological symptoms of dementia

CDT            Clock Draw test

CSI              Caregiver Strain Index

DLB            Dementia with Lewy bodies

EOL            End of life

FAQ            Functional Activities Questionnaire

FAST           Functional Assessment Staging Test

FTD             Frontotemporal dementia

GDS            Geriatric Depression Scale

IADL          Instrumental activities of daily living

MCI             Mild cognitive impairment

Mini-COG   Mini-Cognitive

MMSE         Mini-Mental State Exam

PDD            Parkinson’s disease

PLST           Progressively Lowered Stress Threshold

SLUMS       St. Louis University Mental Status Exam

VaD             Vascular dementia

ZBI              Zarit Burden Interview

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Journal Articles

Borson, S., Scanlan, J.M., Brush, M., Vitallano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15(11), 1021-1027. Evidence Level IV: Nonexperimental Study.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessig, M. (2005). Simplifying detection of cognitive impairment: Comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample.  JAGS, 53(5), 871-874. Evidence Level IV: Nonexperimental Study.

Borson, S., Scanlan, J.M., Watanabe, J., Tu, S.P., & Lessig, M. (2006). Improving identification of cognitive impairment in primary care.  International Journal of Geriatric Psychiatry, 21(4), 349-355.

Carolan Doerflinger, D.M. (2007). How to try this: The Mini-Cog.  AJN, 107(12), 62-70. Available online at http://www.nursingcenter.com/prodev/ce_article.asp?tid=756614

Cummings, J.L., Frank, J.C., Cherry, D., Kohatsu, N.D., Kemp, B., Hewett, L., & Mittman, B. (2002). Guidelines for managing Alzheimer’s disease part I: Assessment. American Family Physician, 65(11), 2263-2272.

Cummings, J.L., Frank, J.C., Cherry, D., Kohatsu, N.D., Kemp, B., Hewett, L., & Mittman, B. (2002). Guidelines for managing Alzheimer’s disease part II: Treatment. American Family Physician, 65(12), 2525-2534.

Goolsby, M.J., & Blackwell, J. (2002). Alzheimer’s disease management. Journal of the American Academy of Nurse Practitioners, 14(8), 338-340.

Maslow, K., & Mezey, M. (2008). How to try this: Recognition of dementia in hospitalized older adults.  AJN, 108(1), 40-49.   Available online at http://www.nursingcenter.com/prodev/ce_article.asp?tid=762396%20

Royall, D.R., Cordes, J.A., & Polk, M. (1998). CLOX: An executive clock drawing task. Journal of Neurology, Neurosurgery, and Psychiatry, 64(5), 588-594.

Tombaugh, T.N., & McIntyre, N.J. (1992). The Mini-Mental State Examination: A comprehensive review. JAGS, 40(9), 922-935. Evidence Level I: Systematic Review.