CHAPTER I INTRODUCTION

A. Background Dementia is not a specific disease. It is a descriptive term for a collection of symptoms that can be caused by a number of disorders that affect the brain. People with dementia have significantly impaired intellectual functioning that interferes with normal activities and relationships. They also lose their ability to solve problems and maintain emotional control, and they may experience personality changes and behavioral problems such as agitation, delusions, and hallucinations. While memory loss is a common symptom of dementia, memory loss by itself does not mean that a person has dementia. Doctors diagnose dementia only if two or more brain functions - such as memory, language skills, perception, or cognitive skills including reasoning and judgment - are significantly impaired without loss of consciousness. There are many disorders that can cause dementia. Some, such as AD, lead to a progressive loss of mental functions. But other types of dementia can be halted or reversed with appropriate treatment. With AD and many other types of dementia, disease processes because many nerve cells to stop functioning, lose connections with other neurons, and die. In contrast, normal aging does not result in the loss of large numbers of neurons in the brain. B. Objective To know the definition of Dementia To know the sign and symptom of dementia To know the factor that includes the dementia To know the nursing care client with dementia

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CHAPTER II DIMENTIA A.BASIC CONCEPT

1. DEFINITION
Dementia is marked by progressive deterioration in intellectual function, memory, and ability to solve problems and learn new skills. Judgment and moral and ethical behaviors decline as personality is altered. Box 12-2 presents the DSM-IV-TR diagnostic criteria for dementia. Unlike delirium, dementia can be of a primary nature and is usually NOT reversible. Dementia is usually a slow and insidious process progressing over months or years. Dementia affects memory and ability to learn new information, or to recall previously learned information. Dementia also compromises intellectual functioning and the ability to solve problems.

2. ONSET
Slow insidious deterioration in cognitive functioning.

3. ESSENTIAL FEATURE
Progressive deterioration in memory, orientation, calculation, and judgment; symptoms do not fluctuate.

4. CAUSE
Progressive deterioration in memory, orientation, calculation, and judgment; symptoms do not fluctuate.

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5. SIGN
5.1. Recent memory loss that affects day to day functions It is normal to forget meetings, colleagues' names or a friend's telephone number occasionally, but then remember them later. A person with dementia may forget things more often, and not remember them at all. 5.2. Difficulty performing familiar tasks

Busy people can be so distracted from time to time that they may leave the carrots on the stove and only remember to serve them when the meal has finished. A person with dementia might prepare a meal and not only forget to serve it, but also forget they made it. 5.3. Problems with language Everyone has trouble finding the right word sometimes, but a person with dementia may forget simple words or substitute inappropriate words, making sentences difficult to understand. 5.4. Disorientation to time and place It is normal to forget the day of the week or your destination for a moment. But people with dementia can become lost on their own street, not knowing where they are, how they got there or how to get back home. 5.5. Poor or decreased judgement Dementia affects a person's memory and concentration, and this in turn affects their judgement. Many activities, such as driving, require good judgement and when this ability is affected, the person will be a risk, not only to themselves, but also to others on the road. 5.6. Problems with abstract thinking Balancing a cheque book may be difficult for many of us. Someone with dementia could forget completely what the numbers are and what needs to be done with them. 5.7. Misplacing things Anyone can temporarily misplace a wallet or keys. A person with dementia may repeatedly put things in inappropriate places. PSYCIATRIC Page 3

5.8. Changes in mood or behavior Everyone becomes sad or moody from time to time. Someone with dementia can have rapid mood swings, for no apparent reason. They can become confused, suspicious or withdrawn. 5.9. Changes in personality People's personalities can change a little with age. But a person with dementia can become suspicious or fearful, or apathetic and uncommunicative. They may also become dis-inhibited, overfamiliar or more outgoing than previously. 5.10. Loss of initiative

It is normal to tire of housework, business activities or social obligations. The person with dementia may lose interest in previously enjoyed activities, or become very passive and require cues prompting them to become involved.

6. COMMON SYMPTOMS INCLUDE

Confusion Personality change Apathy and withdrawal Loss of ability to do everyday tasks.

B.NURSING CARE
1. ASSESSMENT 1.1. Predisposition Factor
Common causes of dementia are: Vascular dementia (multi-infarct) HIV disease Creutzfeldt-Jakob disease General medical condition (brain tumors, subdural hematoma, etc.)

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Underlying cause : the client history Substance abuse Pernicious anemia

1.2. Presipitory Factor

Head trauma Parkinson's disease Huntington's disease Pick's disease Depression

1.3. Behavior
Cognitive impairment: Aphasia: language disturbance, difficulty finding words, using words incorrectly. Apraxia: inability to carry out motor activities despite motor functions being intact (e.g., putting on one's pants, blouse, etc.) Agnosia: loss of sensory ability; inability to recognize or identify familiar objects, such as a toothbrush, or sounds, such as the ringing of the phone; losses ability to problem-solve, plan, organize, or abstract

1.4. Kopping Resources

- Patients - Family - Friends

1.5. Mechanism Kopping

- Influenced by past experience - Regression - Rationalization PSYCIATRIC Page 5

- Denial - Intellectualization - Medical Treatment Psychopharmacology for Dementia Alzheimer's disease (AD) is the most common dementia, accounting for 70% of all dementias , and is the fourth most prevalent cause of death in the adult population. Cholinesterase inhibitors can help in Alzheimer's dementia. Unfortunately, they do not affect ongoing neural destruction. The result of the action is to prevent the metabolism of acetylcholine. Acetylcholine is the neurotransmitter associated with memory and learning. Since acetylcholine is often lower in people with AD, these drugs may temporarily reduce , and later delay, cognitive and behavioral symptoms of dementia. Tacrine ( Cognex) Was the firs anticholinesterase approved for the treatment of Alzheimer's diseasn. Because of liver toxicity, it is rarely used today. Other cholinesterase inhibitors have been useful for many AD clients. Donepezil (Aricep) Another cholinesterase inhibitor, also appears to slow down deterioration in cognitive functions in individuals with mild-to-moderate dementia , without the serious liver toxicity that is attributed to tacrine. Rivastgmini (exelon) and Galantamine (razadyne) are two others in use today. Memantine (Namenda) Is the most recent drug approved at this writing. This drug is the first in a new class of drugs. Memantine is an N-methyl-D-aspartate (NMDA) receptor antagonist that has demonstrated significant effectiveness in clients with moderate-to-severe AD.

2. NURSING DIAGNOSIS
2.1. RISK FOR INJURY Related to (etiology) Sensory dysfunction PSYCIATRIC Page 6

 Cognitive or emotional difficulties Chemical (drugs, alcohol) Biochemical Confusion, disorientation Faulty judgment Loss of short-term memory Lack of knowledge of safety precautions Previous falls Unsteady gait Wandering Provocative behavior As evidenced by (assessment findings/diagnostic cues) Getting into fights with others Choking on inedible object Wandering Burns Falls Getting lost Poisoningwrong medication, wrong dose 2.2. SELF-CARE DEFICIT Impaired ability to perform or complete feeding, bathing, toileting, dressing, and grooming activities for oneself. Related To (Etiology) * Perceptual or cognitive impairment * Neuromuscular impairment * Decreased strength and endurance * Confusion Apraxia (inability to perform tasks that were once routine) Severe memory impairment. As Evidence By (Assessment Findings/ Diagnostic Cues) * Inability to wash properly * Impaired ability to put on or take off necessary items of clotting * Inability to maintain appearance at a satisfactory level * Inability to get to toilet or commode * Inability to carry out proper toilet hygiene

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2.3.IMPAIRED VERBAL COMMUNICATION

Decreased, delayed, or absent ability to receive, process, transmit and use a system of symbols Related to (Etiology) a. Decrease in circulating to the brain b. Physical barrier (e.g., brain tumor, subdural hematoma) c. Deterioration or damage to the neurologic centers in the brain that regulate speech and language d. Biochemical changes in the brain/physiologic conditions Severe memory impairment Escalating anxiety Delusions or illusions As Evidenced By (Assessment Findings/Diagnostic Cues) a. Difficult forming words or sentences b. Difficult expressing thoughts verbally c. Speaks or verbalize with difficult d. Does not cannot speak e. Has difficulty finding the right word for objects (aphasia) Has difficulty identifying object (agnosia) Inability to focus or concentrates on a train thought Impaired comprehension Refers back to first language

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3. PLANNING and INTERVENTION

3.1. RISK FOR INJURY

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3.2. SELF-CARE DEFICIT

Goal and Result Criteria

Long-term goals With guidance and environmental manipulation, client will not hurt himself/herself if falls occur With the aid of an identification bracelet, neighborhood or hospital alert, and enrollment in the safe return program, client will be returned within 3 hours of wandering Client will ingest only correct doses of prescribed medication and appropriate food and fluids 1. 2. 3. 4.

Intervention
Restrict driving. Remove throw rugs and other objects. Minimize sensory stimulation. 1. 2. 3. 4. If clients become verbally upset, listen briefly, give support, then change the topic. 5. Label all room and drawers with pictures. Label often-used object (e.g. hairbrushes and toothbrushes) 6. Install safety bars in bathroom. 7. Surprise clients when they smoke. 8. If the client wanders during the night, put matters on the floor. 9. Have client wear medic-alert bracelet than cannot be removed (with name, address, and telephone number). Provide police department with recent picture. 10. Alert local police and neighbors about wanderer. 11. Put complex locks on door. 12. Place locks at top of door. 13. Encourage physical activity during the day. 14. Explore the feasibility of sensor devices. 15. Enroll the client in the Alzheimers Associations Safe Return program.

Rational
Impaired judgment can lead to accident. Minimizes tripping and falling. Decreased sensory overload, which can increase anxiety and confusion. When attention span is short, clients can be distracted to more productive topics and activities. Might keep client from wandering into other clients room. Increases environmental clues to familiar objects. Prevents fall. Danger of burn is always present. Prevents falls when the client is confused. Client can easily be identified by police, neighbors, or hospital personnel.

5.

6. 7. 8. 9.

Outcome criteria Highest level of functioning will be supported Optimum health is maintained (nutrition, sleep, elimination) Free of fractures, bruises, contusions, burns, and falls

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10. Can reduce time necessary to return client to home or hospital. 11. Reduce opportunity to wander. 12. In moderate and late DAT, ability to look up and reach upward is lost. 13. Physical activity during the day might decrease wandering at night. 14. Provide warning if installing client wanders. Page 11 15. Helps track individuals with dementia who wander and are at risk of getting lost or injury.

Goal and Result Criteria

Long-Term Goals Client will participate in selfcare at optimal level with supervision and guidance. Clients skin will remain intact despite incontinence or prolonged pressure. Client will maintain nutrition, hygiene, dress and toileting activities with appropriate support from others (e.g., care giver, family and staff) Outcome Criteria Clients self-care needs will be met with optimal participation by client. 1.

Intervention
Always have client perform all tasks that they are capable of. Always have client were own clothes, even if in the hospital. 1.

Rational
Maintain self-esteem, uses groups, and minimizes further muscle

2.

2.

Helps maintain clients identity and dignity.

3.

Use clotting with elastic, and substitute fastening tape (Velcro) for buttons and zippers. Label clotting items with name and name of item.

3.

Minimizes clients confusion, and increases independence of functioning.

4.

4.

Helps identify clients if they wander, and gives caregivers additional clues when aphasia or agnosia occurs. Client can focus on small pieces of information more easily allows client to perform at optimum level.

5.

Give steps by step instructions whenever necessary (e.g. take this blouseput in one arm now the next armpull it together in the frontnow)

5.

3.3.IMPAIRED VERBAL COMMUNICATION

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Goal and Result Criteria

Long-Terms Goals Client will communicate basic needs with the use of visual and verbal clues when needed Client will communicate important thoughts with the use visual and verbal clues when needed Clients family and caregiver demonstrate ability to minimize clients agitation and fear when client is delusional or having illusions Outcome Criteria Communicates with aid of variety of verbal and nonverbal techniques for optimum period of time.

Intervention
1. Use of variety of nonverbal techniques to enhance communication: a. Point, touch, or demonstrate an action while talking about it. b. Ask the clients to point to parts of their body or things that they want to communicate about. c. When client is searching for a particular word, guess at what is being said and ask if you are correct (eg, You are pointing to your mouth, saying pain. Is it your dentures? No. is your mouth sore? Yes. OK, let me take a look to see if I can tell what is hurting you.). Always ask client to confirm whether your guess is correct. d. Use of cue cards, flash card, alphabet letters, signs and pictures on doors to various rooms is often helpful for many clients and their families (eg, bathroom, Charles bedroom). Use of the pictures is helpful when ability to read decreases. 2. Encourage reminiscing about

Rational
1. Both delirium and dementia can pose huge communication problems, and often alternative nonverbal or verbal methods have to be used.

2. Remembering accomplishments and shared joys Page 13

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happy times in life. 3. If a client gets into an argument with another client, stop the argument and get them out of each others way. After a short while (5 minutes) explain to each client matter-of-factly why you had to intervene. 4. Reinforce clients speech through pictures, nonverbal gestures, Xs on calendars and other methods used to anchor clients in reality.

helps distract client from deficit and gives meaning to existence. 3. Prevents escalation to physical acting out. Shows respect for clients right to know. Explaining in an adult manner helps maintain self-esteem.

4. When aphasia starts to hinder communication, alternate methods of communication need to be instituted.

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CHAPTER III CLOSING

CONCLUSION Dementia is marked by progressive deterioration in intellectual function, memory, and ability to solve problems and learn new skills. Judgment and moral and ethical behaviors decline as personality is altered. Box 12-2 presents the DSM-IV-TR diagnostic criteria for dementia. ONSET . Slow insidious deterioration in cognitive functioning. ESSENTIAL FEATURE : Progressive deterioration in memory, orientation, calculation, CAUSE : Progressive deterioration in memory, orientation, calculation, and judgment; WARNING SIGN Recent memory loss that affects day to day functions Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgement Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative COMMON SYMPTOMS INCLUDE Confusion Personality change Apathy and withdrawal Loss of ability to do everyday tasks.

and judgment; symptoms do not fluctuate. symptoms do not fluctuate.

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Reference
Manual of Psychiatric Nursing Care Plan. Elizabeth M. Varcarolis http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Dementia_diagnosis_and_early_ signs?open

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