Dementia, now clinically termed Major Neurocognitive Disorder (MND), represents a significant decline in cognitive function that impairs daily living. It’s crucial to understand that MND is not a natural part of aging but a progressive condition requiring specialized care. Alzheimer’s disease stands as the most prevalent form of MND, accounting for approximately 70% of cases. As the condition advances, individuals with dementia face increasing challenges in self-care, safety, and overall well-being. This guide delves into the essential aspects of nursing care for dementia, focusing on the critical role of Nanda Nursing Diagnosis Dementia Care Plans in providing structured and effective support.
The Nursing Process in Dementia Care
Effective dementia care hinges on a structured nursing process. As MND progresses, individuals may experience self-care deficits across various activities, from bathing and grooming to feeding and toileting. Alzheimer’s disease, in particular, can lead to swallowing difficulties and an elevated risk of aspiration pneumonia. Furthermore, impaired judgment and reasoning can contribute to falls as patients may attempt to move unassisted despite mobility limitations. The complexities of these neurocognitive disorders necessitate a comprehensive nursing approach that prioritizes safety, emotional well-being, and addresses the mental challenges faced by both patients and their families.
Nursing Assessment for Dementia
The cornerstone of quality nursing care is a thorough nursing assessment. This initial step involves gathering comprehensive physical, psychosocial, emotional, and diagnostic data. For dementia and Alzheimer’s disease, this assessment encompasses both subjective and objective information to establish a clear understanding of the patient’s condition and needs.
Review of Health History
1. Comprehensive Medical History Review: Obtain a detailed medical history from the patient and/or caregiver. Certain pre-existing conditions are known to elevate the risk of neurocognitive disorders:
2. Identification of Nonmodifiable Risk Factors: Recognize and document nonmodifiable risk factors that may contribute to MND and Alzheimer’s disease:
- Advancing Age: The risk significantly increases with age.
- Family History: A family history of MND or Alzheimer’s disease in first-degree relatives is a substantial risk factor.
- Genetic Predisposition: Specific genetic mutations are linked to increased risk.
- Down Syndrome: Individuals with Down syndrome have a higher incidence of developing Alzheimer’s.
- Female Gender: Women are statistically more likely to be diagnosed with Alzheimer’s disease.
3. Family History of Neurocognitive Disorders: Inquire specifically about family history, as the risk of dementia is heightened with a first-degree relative affected by MND.
4. Substance Abuse History: Discuss substance abuse history, including alcohol and smoking, with the patient and caregiver. Chronic heavy alcohol consumption is associated with increased dementia risk, especially early-onset dementia. Smoking is linked to vascular disease and potentially dementia.
5. Medication Review: Scrutinize the patient’s medication list. Certain medications, including some analgesics, antihistamines, CNS agents, muscle relaxants, and respiratory medications, can induce delirium and confusion, particularly in older adults.
6. Baseline MND Symptom Assessment: Discuss MND symptoms to establish a baseline understanding of cognitive changes. Patients may not always be aware of their cognitive decline. Given the progressive nature of dementia, documenting a timeline and differentiating from acute changes in mental status is crucial.
7. Functional Status and Instrumental ADLs: Determine the patient’s current functional status, including instrumental Activities of Daily Living (IADLs). Compassionately inquire about their self-care routine at home.
- Assistance with ADLs: Determine if assistance is needed for bathing, dressing, cooking, and eating.
- Driving Ability: Assess if the patient still drives and if it is safe.
- Home Safety: Evaluate home safety, including fire escape ability and risk of wandering.
- IADL Capacity: Inquire about IADLs like appointment scheduling and financial management.
These insights are vital for diagnosis, monitoring MND progression, and developing effective care plans.
8. Hospitalization Risk Factors: Identify health and safety risk factors during hospitalization. Hospitalization can exacerbate confusion in patients with MND due to unfamiliar environments, increasing risks of agitation, falls, and elopement.
9. Sleep Pattern Review: Review typical sleep patterns and routines. Patients with MND often experience disruptions in their sleep-wake cycle, leading to fragmented and disrupted sleep. Poor sleep can worsen neurological deficits, confusion, irritability, and alertness, and contribute to sundowning, a phenomenon characterized by paranoid delusions and increased confusion in the evening.
Alt text: An elderly patient with dementia rests in a hospital bed, highlighting the importance of sleep assessment in dementia nursing care.
Physical Assessment
1. Observation of Appearance, Gait, and Affect: Assess the patient’s overall appearance, hygiene, dress, and posture. Observe gait and balance. Note affect, responsiveness, and mood for clues about cognitive status.
2. Orientation Assessment: Evaluate the patient’s level of orientation across key domains:
- Person, Place, Time, and Situation: Assess orientation to these fundamental aspects.
- Speech Clarity: Evaluate speech for clarity and coherence.
- Ability to Follow Directions: Assess the capacity to understand and follow simple instructions.
- Attention Span and Concentration: Observe attention span and ability to concentrate.
- Response Appropriateness: Judge the appropriateness of verbal and nonverbal responses.
3. Standardized Cognitive Assessments: Utilize standardized neuropsychological tests, often administered by physicians or advanced providers. Nurses may assist with or review results of tests like:
- Mini-Mental State Examination (MMSE): A widely used tool to screen for cognitive impairment.
- Saint Louis University Mental Status (SLUMS) exam: Another cognitive screening tool, considered more sensitive than MMSE for mild cognitive impairment.
- Montreal Cognitive Assessment (MoCA): A more detailed cognitive assessment, sensitive to subtle cognitive decline.
4. Symptom Observation Across Dementia Stages: Observe for symptoms associated with different stages of MND and Alzheimer’s disease:
- Preclinical Stage: Brain changes occur years before symptoms. Assessments and neurologic testing are typically normal.
- Mild Stage: Memory loss becomes noticeable (forgetfulness, confusion about familiar places). Daily tasks take longer, money management becomes harder, spontaneity decreases, and anxiety-related personality changes may emerge. Diagnosis often occurs at this stage.
- Moderate Stage: Memory loss and confusion worsen. Language difficulties (written, read, spoken), impaired logical thinking, and challenges learning new things are evident. Anger, wandering, hallucinations, paranoia, and irritability are common behavioral changes.
- Severe Stage: Brain atrophy is widespread. Patients fail to recognize familiar faces and lose meaningful communication abilities. Physical symptoms include weight loss, swallowing difficulties, increased sleep, and loss of bladder/bowel control. Bedbound status and death from secondary causes like aspiration pneumonia are frequent.
Alt text: A nurse administers a cognitive assessment test to a senior patient, emphasizing the role of standardized tools in evaluating dementia.
Diagnostic Procedures
1. Blood Sample Analysis: Laboratory tests help rule out other conditions mimicking dementia:
- Complete Blood Count (CBC)
- Urinalysis
- Metabolic Panel
- Vitamin B12 and Folic Acid Levels
- Thyroid Function Tests
- Serological Tests for Syphilis and HIV
- Selective tests (based on clinical suspicion): Erythrocyte Sedimentation Rate, Lumbar Puncture, Heavy Metal Screen, Ceruloplasmin Levels, Lyme Disease Titer, Serum Protein Electrophoresis.
2. Diagnostic Imaging: Brain imaging is crucial for initial evaluation, early-onset dementia, atypical presentations, or rapid cognitive decline. Common imaging modalities include:
- Brain MRI: Evaluates vascular and ischemic disease, localized brain areas, and global atrophy.
- Computerized Tomography (CT): Rules out acute neurologic conditions like stroke or brain masses causing sudden symptoms but offers limited diagnostic aid for dementia itself.
Nursing Interventions for Dementia
Nursing interventions are vital for managing dementia and supporting patients and their families.
1. Medication Administration: Administer prescribed medications to enhance cognitive function and manage secondary symptoms.
- Cognitive Enhancers:
- NMDA antagonists (e.g., Namenda/memantine): Reduce glutamine’s action to protect brain cells.
- Cholinesterase inhibitors (e.g., galantamine, rivastigmine, donepezil): Slow symptom progression by preventing acetylcholine breakdown.
- Anti-amyloid beta monoclonal antibodies (e.g., donanemab, lecanemab): Disease-modifying treatments for mild Alzheimer’s, targeting amyloid plaques.
- Symptom Management:
- Antidepressants/Mood Stabilizers: Manage irritability, depression, and rage.
- Neuroleptics: Address hallucinations and delusions.
- Anxiolytics: Manage anxiety and agitation.
2. Lifestyle Modification Promotion: Encourage lifestyle changes to optimize cognitive function:
- Sleep Enhancement: Promote regular sleep routines and address sleep disturbances.
- Anti-inflammatory Diet: Recommend a diet rich in fruits, vegetables, and omega-3 fatty acids.
- Regular Physical Activity: Encourage exercise to improve overall health and potentially cognitive function.
- Sensory Loss Management: Treat hearing and vision loss with aids.
- Stress Reduction: Implement stress-reduction techniques.
- Avoidance of Heavy Alcohol Use
- Management of Cholesterol, Blood Pressure, and Glucose: Maintain healthy levels.
3. Safe Environment Provision: Create a safe and supportive environment:
- Reduce Clutter and Noise: Minimize environmental distractions.
- Remove Hazards: Eliminate dangerous objects to prevent accidents.
- Maintain Tidy Space: Promote organization to reduce confusion.
- Implement Monitoring Systems: Use monitoring for patients at risk of wandering or falls.
4. Cognitive Stimulation Encouragement: Support cognitive function through mental activities:
- Mentally Stimulating Activities: Encourage puzzles, brain teasers, reading, and games.
5. Caregiver Involvement and Education: Engage and educate caregivers:
- Provide Disease Process Information: Educate families on what to expect as dementia progresses.
- Reassurance and Redirection Techniques: Teach caregivers to reassure and redirect disoriented patients instead of constant correction.
6. Patient and Family Support: Offer comprehensive support:
- Support Organizations and Societies: Connect families with resources and support networks.
- Financial and Respite Resources: Provide information on available financial aid and respite care services.
NANDA Nursing Diagnosis Dementia Care Plans: Examples
NANDA nursing diagnosis dementia care plans are essential tools for prioritizing care and guiding nursing interventions for both short-term and long-term goals. Here are examples of nursing care plans based on common NANDA diagnoses for dementia:
1. Disturbed Sensory Perception (Visual)
NANDA Nursing Diagnosis: Disturbed Sensory Perception (Visual)
Related Factors:
- Alzheimer’s Disease
- Sleep Disorders
- Depression
- Excessive Stimuli
- Medication Side Effects
Evidenced By:
- Changes in Sensory Acuity
- Personality Changes
- Irritability
- Hallucinations
- Altered Communication Patterns
- Confusion
Expected Outcomes:
- Patient will accurately identify objects and sounds.
- Patient will maintain their baseline cognitive level.
Nursing Assessments:
- Cognitive Level Assessment: Conduct a thorough history and neurologic evaluation, including orientation, mental acuity, and behavioral changes.
- Sensory Abnormality Assessment: Assess auditory and visual senses for abnormalities, as these are common in older adults with dementia and increase the risk of falls and injuries.
- Contributing Factor Assessment: Identify potential contributing factors such as neurological disorders, medications, electrolyte imbalances, excessive stimuli, and underlying health conditions.
Nursing Interventions:
- Treatment of Exacerbating Causes: Manage conditions like high fevers, polypharmacy, or electrolyte imbalances (hyponatremia, hypocalcemia) that can worsen sensory perception.
- Visual and Auditory Aids: Encourage use of glasses, magnifying glasses, brighter lighting, and hearing aids to improve sensory input.
- Fall Precautions: Implement fall precautions, including bedside rails, bed alarms, call light within reach, and low bed position.
- Temperature Extremes Avoidance: Protect patients from extreme temperatures due to potential tactile issues.
- Reassurance and Distraction: Offer reassurance and distraction for hallucinations and delusions; avoid arguing with the patient’s perceptions.
- Stimulation and Rest Balance: Balance social stimulation with adequate rest to prevent sensory overload.
2. Impaired Memory
NANDA Nursing Diagnosis: Impaired Memory
Related Factors:
- Brain Injury
- Neurological Impairment
- Mild Cognitive Impairment
Evidenced By:
- Persistent Forgetfulness
- Persistent Inability to Recall Events
- Persistent Inability to Recall Familiar Names/Information
- Persistent Inability to Learn New Information
- Persistent Inability to Learn New Skills
Expected Outcomes:
- Patient will demonstrate memory-enhancing techniques.
- Patient will show improved memory in daily activities and interactions.
Nursing Assessments:
- Overall Cognitive Function Assessment: Use screening tools like MoCA. Assess for reversible conditions (electrolyte imbalances, medications, hypoxia, hypothyroidism, substance abuse, infections).
- Medication List Review: Review medication list for accuracy and potential cognitive side effects, especially in older adults.
- Sleep Quality Assessment: Assess sleep patterns and quality; address sleep disorders like obstructive sleep apnea.
- Safety Concern Assessment: Assess for risks of skin breakdown, aspiration pneumonia, falls, and elopement using facility-specific tools.
Nursing Interventions:
- Environmental Orientation: Orient patient to the environment as needed to promote awareness and reduce anxiety.
- Cognitive Memory Techniques: Assist patient in using memory aids like calendars and alarms.
- Medication Box Assistance: Help set up medication boxes for medication adherence.
- Good Sleep Hygiene: Encourage daily exercise, light exposure, regular sleep schedule, and avoidance of large meals before bed.
- Memory-Enhancing Techniques Education: Educate on concentration, repetition, mental associations, and strategic item placement. Introduce cognitive rehabilitation programs.
Alt text: A caregiver assists a senior patient with organizing medications, illustrating a practical intervention for impaired memory in dementia care.
3. Self-Care Deficit
NANDA Nursing Diagnosis: Self-Care Deficit
Related Factors:
- Weakness
- Depression
- Cognitive Decline
- Impaired Judgment
- Poor Decision-Making
- Inability to Communicate Needs
- Incontinence
- Declining Motor Skills
Evidenced By:
- Transferring/Ambulation Difficulties
- Inability to Safely Prepare Food
- Inability to Handle Utensils
- Swallowing Difficulties
- Inappropriate Clothing Choices
- Difficulty Dressing
- Re-wearing Dirty Clothing
- Inability to Regulate Bath Water Temperature
- Inability to Recognize Urge to Eliminate
- Needing Reminders for Tasks
- Inability to Maintain Hygiene
Expected Outcomes:
- Patient will maintain independence in dressing, bathing, and toileting as long as possible.
- Patient will safely prepare meals and feed themselves within abilities.
- Patient will alert caregiver to needs.
Nursing Assessments:
- Ability Level Assessment: Observe patient’s physical and mental capabilities to identify areas for support and safety concerns.
- Caregiver Support Determination: Assess caregiver understanding and capacity to provide home support; suggest paid support or community resources if needed.
Nursing Interventions:
- Schedule and Routine Maintenance: Encourage a daily routine for dressing, bathing, meals, and elimination.
- Simple Choice Offerings: Provide simple choices to avoid overwhelming the patient.
- Self-Care Resource Consideration: Implement adaptive equipment like handheld showerheads, grab bars, stairlifts, and easy-grip cutlery.
- Dressing Simplification: Lay out clothing, use Velcro closures instead of buttons/zippers, and opt for slip-on shoes.
- Signage Use: Utilize labels, notes, whiteboards, clocks, and timers as reminders throughout the house.
4. Social Isolation
NANDA Nursing Diagnosis: Social Isolation
Related Factors:
- Declining Cognition
- Speech Difficulty
- Personality Changes
- Confusion
- Physical Deconditioning
- Depression
Evidenced By:
- Forgetting Names/Dates
- Repeating Questions
- Inability to Drive
- Inability to Recognize Others
- Need for Self-Care Assistance
- Incontinence
- Disturbed Sleep
- Nonverbal Communication
- Agitation/Combativeness
- Paranoia
Expected Outcomes:
- Patient will maintain meaningful relationships as long as possible.
- Patient will seek social support through groups and community.
- Patient will maintain an active and enriched lifestyle.
Nursing Assessments:
- Support System Assessment: Assess for family, friends, or community support systems.
- Physical and Mental Limitation Determination: Identify physical and cognitive limitations contributing to isolation.
- Mental Illness Barrier Assessment: Assess for feelings of embarrassment, hopelessness, anxiety, and depression contributing to isolation.
Nursing Interventions:
- Cognitive Level Activities: Provide appropriate games, books, music, and exercise programs. Encourage family involvement in hobbies.
- Adult Daycare Referral: Refer to adult daycare centers for socialization.
- Memory Reminiscence: Use music, family photos, and questions about the past to stimulate memory and sense of self.
- Outdoor Engagement: Encourage outdoor activities and social interaction in natural settings.
5. Risk for Falls
NANDA Nursing Diagnosis: Risk for Falls
Related Factors:
- Impulsiveness
- Advanced Age
- Poor Mobility
- Loss of Perception
- Assistive Device Use
- Incontinence
- Vision Loss
- Poor Balance
- Decreased Coordination
- Misinterpretation of Environment
- Gait Abnormalities
- Confusion
- Delirium
- Medications
- Depression
- Caregiver Strain
Expected Outcomes:
- Patient will remain free from falls.
- Patient will correctly use assistive devices.
- Patient will call for help before ambulating.
Nursing Assessments:
- Fall Risk Assessment: Perform fall risk assessments using scales like the Morse Fall Scale and consider cognitive function (MMSE score).
- Muscle Strength and Coordination Assessment: Assess gait, balance, motor skills, and assistive device use.
- Judgment and Perception Assessment: Assess judgment, perception, and sundowning tendencies.
Nursing Interventions:
- Items Within Reach: Keep frequently used items within easy reach.
- Fall Alert Device Use: Utilize bed/chair alarms and personal fall alert devices.
- Environment Uncluttering: Keep walking areas clear of clutter and hazards.
- Visual Acuity Consideration: Address vision issues with night lights, daylight access, lamps, and contrast enhancements.
Alt text: A nurse assists an elderly patient using a walker, illustrating fall prevention strategies in dementia care.
