Dementia, now clinically termed Major Neurocognitive Disorder (MND), signifies a substantial decline in cognitive abilities that impairs daily functioning. It’s crucial to understand that MND is not a natural part of aging but a progressive condition requiring diligent nursing care. Alzheimer’s disease stands as the most prevalent form of MND, accounting for approximately 70% of cases, characterized by its gradual progression through preclinical, mild, moderate, and severe stages. Currently, there is no cure for Alzheimer’s, making supportive and therapeutic nursing interventions paramount.
The Nursing Process in Dementia Care
As MND advances, patients frequently develop self-care deficits, affecting essential activities like bathing, dressing, eating, and toileting. Swallowing difficulties, a common symptom in later stages of Alzheimer’s, increase the risk of aspiration pneumonia, a life-threatening complication. Furthermore, impaired judgment and reasoning contribute to a high incidence of falls. Studies reveal alarming statistics, with a significant mortality rate within six months post-hospital discharge for dementia patients admitted for conditions like pneumonia or hip fractures.
Nurses play a vital role in managing the diverse physical and emotional challenges presented by MND. Prioritizing patient safety and addressing the profound emotional and psychological impact on both patients and their families are fundamental to delivering effective nursing care.
Nursing Assessment for Dementia
The initial step in providing nursing care is a thorough assessment, encompassing physical, psychosocial, emotional, and diagnostic data. This section will explore both subjective and objective data collection relevant to dementia and Alzheimer’s disease.
Health History Review
1. Comprehensive Medical History: Gather a detailed medical history from the patient and/or caregiver. Identify pre-existing conditions that elevate the risk of neurocognitive disorders, including cardiovascular disease, hypertension, diabetes, and previous strokes or head injuries.
2. Nonmodifiable Risk Factor Identification: Recognize and document nonmodifiable risk factors associated with Alzheimer’s disease/MND:
- Advancing Age: The risk significantly increases with age, particularly after 65.
- Family History: A family history of MND or Alzheimer’s disease in first-degree relatives increases susceptibility.
- Genetic Predisposition: Specific genetic mutations are linked to increased risk, especially in early-onset Alzheimer’s.
- Down Syndrome: Individuals with Down syndrome have a higher likelihood of developing Alzheimer’s.
- Female Gender: Women are slightly more prone to Alzheimer’s than men, potentially due to hormonal factors and longevity.
3. Family History of Dementia: Inquire specifically about family history of dementia, noting any first-degree relatives diagnosed with MND, as this significantly elevates the patient’s risk.
4. Substance Abuse History: Obtain a detailed substance abuse history from the patient and/or caregiver. Heavy alcohol consumption and smoking are known neurotoxins. Alcohol use disorders are associated with a heightened risk of dementia, especially early-onset forms, while smoking increases the risk of vascular dementia.
5. Medication Review: Thoroughly review the patient’s medication list. Certain medications, such as analgesics, antihistamines, CNS agents, muscle relaxants, and some respiratory medications, can induce delirium and confusion in older adults as adverse effects. Polypharmacy is a significant risk factor for cognitive impairment.
6. Baseline Symptom Assessment: Discuss MND symptoms with the patient and caregiver to establish a baseline. Note the progressive nature of symptoms and differentiate from acute changes in mental status that may indicate delirium or other conditions. Assess the onset, duration, and progression of cognitive decline.
7. Functional Status Evaluation: Determine the patient’s current functional status, particularly Instrumental Activities of Daily Living (IADLs). Compassionately inquire about their self-care routine at home:
- ADL Dependence: Assess the level of assistance needed for Activities of Daily Living (ADLs) like bathing, dressing, cooking, and eating.
- Driving Safety: Evaluate driving ability and safety concerns.
- Home Safety: Assess home safety, including the ability to evacuate in emergencies, risk of wandering, and general safety awareness.
- IADL Capacity: Inquire about IADLs such as appointment scheduling, medication management, and financial management.
These details are critical for diagnosing MND and monitoring disease progression.
8. Hospitalization Risk Factors: Identify health and safety risk factors during hospitalization. Hospitalization can exacerbate confusion in MND patients due to the unfamiliar environment, increasing agitation, falls, and elopement risks.
9. Sleep Pattern Review: Review typical sleep patterns and routines with the patient and/or caregiver. MND often disrupts the sleep-wake cycle, leading to fragmented and disrupted sleep. Poor sleep worsens neurological deficits, including confusion, irritability, and reduced alertness, and can contribute to sundowning.
Physical Assessment for Dementia
1. General Observation: Assess the patient’s appearance, gait, and general affect. Observe hygiene, dress, posture, gait, balance, affect, responsiveness, and mood for clues regarding cognitive status.
2. Orientation and Mental Status: Assess orientation to person, place, time, and situation. Evaluate speech clarity, ability to follow directions, attention span, concentration, and appropriateness of responses.
3. Standardized Cognitive Assessments: Utilize standardized neuropsychological tests, typically administered by physicians or advanced practice providers. Nurses may assist with or review results of tests such as:
- Mini-Mental State Examination (MMSE): A widely used brief cognitive assessment tool.
- Saint Louis University Mental Status (SLUMS) Exam: Another brief tool, considered slightly more sensitive than MMSE for mild cognitive impairment.
- Montreal Cognitive Assessment (MoCA): A more detailed assessment sensitive to mild cognitive dysfunction.
4. Symptom Observation by Stage: Observe for symptoms indicative of different stages of MND, particularly Alzheimer’s disease:
- Preclinical Stage: Brain changes occur without noticeable symptoms. Neurological testing is typically normal.
- Mild Stage: Memory loss becomes noticeable, with confusion and forgetfulness about familiar places. Daily tasks take longer, money management becomes challenging, spontaneity decreases, and anxiety may increase. Diagnosis often occurs in this stage.
- Moderate Stage: Memory loss and confusion worsen. Language difficulties (written, read, spoken), impaired logical thinking, and difficulty learning new things emerge. Agitation, wandering, hallucinations, paranoia, and irritability are common.
Alt text: Nurse administers Mini-Mental State Examination (MMSE) for cognitive assessment.
- Severe Stage: Brain atrophy is widespread. Patients fail to recognize familiar faces, cannot communicate meaningfully, and exhibit physical symptoms such as weight loss, swallowing difficulties, increased sleep, and loss of bladder and bowel control. Bedridden status and death from secondary causes like aspiration pneumonia are common.
Diagnostic Procedures for Dementia
1. Blood Sample Analysis: Laboratory tests help rule out reversible conditions mimicking dementia:
- Complete Blood Count (CBC): To assess general health and rule out infection.
- Urinalysis: To check for urinary tract infections, which can cause confusion in older adults.
- Metabolic Panel: To evaluate electrolyte imbalances and kidney/liver function.
- Vitamin B12 and Folate Levels: Deficiencies can cause cognitive impairment.
- Thyroid Function Tests: Hypothyroidism can mimic dementia symptoms.
- Serological Tests for Syphilis and HIV: To rule out infections that can cause neurological damage.
- Selected Tests (as indicated): Erythrocyte sedimentation rate, lumbar puncture, heavy metal screen, ceruloplasmin levels, Lyme disease titer, serum protein electrophoresis may be ordered based on clinical suspicion.
2. Diagnostic Brain Imaging: Brain imaging is crucial for initial evaluation, early-onset dementia, atypical presentations, or rapid cognitive decline:
- Brain Magnetic Resonance Imaging (MRI): Evaluates vascular disease, ischemic changes, localized or global brain atrophy. Provides detailed anatomical views.
- Computerized Tomography (CT): Primarily to rule out acute neurological issues like stroke or brain tumors causing sudden symptoms. Less helpful for specific dementia diagnosis but important for differential diagnosis.
Nursing Interventions for Dementia
Nursing interventions are crucial for managing dementia and improving patient quality of life.
1. Medication Administration: Administer prescribed medications to manage cognitive symptoms and secondary conditions:
- NMDA Antagonists (e.g., Memantine/Namenda): Reduce glutamate activity, protecting against excitotoxicity.
- Cholinesterase Inhibitors (e.g., Donepezil, Rivastigmine, Galantamine): Slow symptom progression by increasing acetylcholine levels in the brain.
- Anti-amyloid Beta Monoclonal Antibodies (e.g., Donanemab/Kisunla, Lecanemab/Leqembi): Disease-modifying treatments for mild Alzheimer’s, targeting amyloid plaques.
Alt text: Alzheimer’s and dementia medications: cholinesterase inhibitors and NMDA antagonists.
- Medications for Secondary Symptoms: Antidepressants, mood stabilizers, neuroleptics, and anxiolytics to manage depression, irritability, hallucinations, delusions, anxiety, and agitation.
2. Lifestyle Modification Encouragement: Promote lifestyle changes to optimize cognitive function:
- Sleep Hygiene: Improve sleep quality and consistency.
- Anti-inflammatory Diet: Recommend a diet rich in fruits, vegetables, and omega-3 fatty acids.
- Regular Physical Activity: Encourage regular exercise to improve cardiovascular health and cognitive function.
- Sensory Loss Management: Address hearing and vision loss with appropriate aids.
- Stress Reduction: Implement stress reduction techniques.
- Alcohol and Smoking Avoidance: Advise against heavy alcohol use and smoking.
- Chronic Disease Management: Maintain healthy cholesterol, blood pressure, and glucose levels.
3. Safe Environment Provision: Create a safe and structured environment:
- Reduce Clutter and Noise: Minimize environmental distractions.
- Remove Hazards: Eliminate dangerous objects to prevent falls and injuries.
- Monitoring Systems: Implement monitoring for wandering or unsafe behaviors.
4. Cognitive Stimulation Promotion: Encourage mentally stimulating activities:
- Brain Games and Puzzles: Crossword puzzles, brain teasers, and memory games.
- Reading and Learning: Engage in reading and new learning activities.
5. Caregiver Involvement and Education: Engage and support caregivers:
- Disease Process Education: Provide comprehensive information about MND progression.
- Communication Techniques: Educate on redirection and reassurance techniques to manage disorientation and agitation.
- Respite Care: Recommend respite care options to prevent caregiver burnout.
6. Patient and Family Support: Offer emotional and practical support:
- Support Groups: Connect patients and families with support organizations and societies.
- Resource Navigation: Assist with accessing financial, respite, and community resources.
Dementia Nursing Care Plans and NANDA Diagnoses
Nursing care plans based on NANDA-I diagnoses guide prioritized assessments and interventions for both short-term and long-term care goals in dementia. Here are examples of relevant nursing diagnoses for dementia:
1. Disturbed Sensory Perception
NANDA Diagnosis: Disturbed Sensory Perception
This diagnosis is relevant due to cortical disturbances in Alzheimer’s disease affecting visual processing. Neurofibrillary tangles and plaques in visual cortical areas lead to degeneration and atrophy, impairing higher visual abilities.
Related Factors:
- Alzheimer’s Disease
- Sleep Disorders
- Depression
- Excessive Stimuli
- Medication Side Effects
As Evidenced By:
- Changes in Sensory Acuity
- Personality Changes
- Irritability
- Hallucinations
- Altered Communication Patterns
- Confusion
Expected Outcomes:
- Patient will accurately identify common objects and sounds.
- Patient will maintain baseline cognitive function in sensory processing.
Nursing Assessments:
- Cognitive Level Assessment: Complete a full history and neurologic evaluation, including orientation, mental acuity, and behavioral changes related to sensory processing.
- Sensory Function Assessment: Assess visual and auditory senses for abnormalities, as these are commonly affected in dementia and increase risks of falls and injuries.
- Contributing Factor Assessment: Identify factors like neurological disorders, medications, electrolyte imbalances, and environmental stimuli that can exacerbate sensory disturbances.
Nursing Interventions:
- Treat Exacerbating Causes: Manage underlying conditions like fevers, polypharmacy, and electrolyte imbalances (especially hyponatremia and hypocalcemia).
- Sensory Aids: Encourage use of visual and auditory aids like corrective glasses, magnifying glasses, brighter lighting, and hearing aids.
- Fall Precautions: Implement comprehensive fall precautions, including bed rails, bed alarms, call light accessibility, and low bed positioning.
- Temperature Safety: Instruct patient to avoid extreme temperatures due to tactile sensory issues common in dementia.
- Reassurance and Distraction: Offer reassurance and distraction techniques to manage hallucinations and delusions; avoid arguing with the patient’s perceptions.
- Balanced Stimulation: Balance social stimulation with rest to prevent sensory overload.
2. Impaired Memory
NANDA Diagnosis: Impaired Memory
This diagnosis addresses the core symptom of dementia – a significant and progressive decline in cognitive domains, particularly memory.
Related Factors:
- Brain Injury
- Neurological Impairment
- Mild Cognitive Impairment
As Evidenced By:
- Persistent Forgetfulness
- Persistent Inability to Recall Events
- Persistent Inability to Recall Familiar Names or 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 function in daily activities and interactions (within the context of progressive decline).
Nursing Assessments:
- Overall Cognitive Function Assessment: Use screening tools like MoCA. Assess for reversible causes of acute cognitive worsening, such as electrolyte imbalances, medications, hypoxia, hypothyroidism, substance abuse, and infections.
- Medication Review: Review medication list for accuracy, appropriateness, and potential cognitive side effects, especially in older adults.
- Sleep Quality Assessment: Assess for sleep disturbances, as poor sleep exacerbates cognitive impairment. Investigate symptoms of sleep disorders like obstructive sleep apnea.
- Safety Concerns Assessment: Evaluate risks for skin breakdown, aspiration pneumonia, falls, and elopement, using appropriate screening tools.
Nursing Interventions:
- Environmental Orientation: Orient patient to the environment frequently to promote awareness and reduce anxiety.
- Cognitive Memory Techniques: Assist patient in using memory aids like calendars, alarms, and written cues.
- Medication Box Assistance: Help set up medication boxes to improve medication adherence and monitoring.
- Sleep Hygiene Education: Encourage good sleep hygiene practices: exercise, light exposure, consistent sleep schedule, avoid large meals before bed.
- Memory-Enhancing Techniques Education: Educate on techniques like concentration, repetition, mental associations, and strategic placement of items. Refer to cognitive rehabilitation programs.
3. Self-Care Deficit
NANDA Diagnosis: Self-Care Deficit (Specify area: Bathing, Dressing, Feeding, Toileting)
This diagnosis addresses the progressive loss of ability to perform self-care activities due to cognitive and motor decline in dementia.
Related Factors:
- Weakness
- Depression
- Cognitive Decline
- Impaired Judgment
- Poor Decision-Making
- Inability to Communicate Needs
- Incontinence
- Declining Motor Skills
As Evidenced By:
- Transferring or Ambulation Difficulties
- Inability to Safely Prepare Food
- Inability to Handle Utensils
- Swallowing Difficulties
- Lack of Judgment in Clothing Choices
- Difficulty Dressing Self
- Re-wearing Dirty Clothing
- Inability to Safely Regulate Bath Water Temperature
- Inability to Recognize Urge or Remove Clothing for Elimination
- Needing Reminders or Coaching for Tasks
- Inability to Maintain Hygiene
Expected Outcomes:
- Patient will maintain independence in self-care for as long as possible.
- Patient will safely prepare meals and feed self within abilities.
- Patient will communicate self-care needs to caregiver.
Nursing Assessments:
- Ability Level Assessment: Observe patient’s physical and mental capabilities to identify areas of self-care deficit and safety concerns.
- Caregiver Support Assessment: Determine caregiver availability, understanding of patient needs, and ability to provide support. Assess for caregiver strain and need for resources.
Nursing Interventions:
- Structured Routine: Maintain a daily routine for dressing, bathing, meals, and toileting to promote organization and independence.
- Simple Choices: Offer simple choices to empower patient while minimizing overwhelm.
- Assistive Resources: Implement assistive devices to improve safety and task completion: handheld showerheads, grab bars, stairlifts, easy-grip utensils.
- Simplified Dressing: Simplify dressing by using clothes without buttons/zippers and Velcro closures. Lay out clothing choices for patient.
- Environmental Signage: Use labels, notes, clocks, and timers as reminders to enhance self-care activities.
Alt text: Caregiver aids dementia patient in dressing, supporting self-care.
4. Social Isolation
NANDA Diagnosis: Social Isolation
This diagnosis addresses the reduced social interaction and loneliness experienced by dementia patients due to cognitive and behavioral changes.
Related Factors:
- Declining Cognition
- Difficulty with Speech
- Personality Changes (Anger, Inappropriate Behavior)
- Confusion
- Physical Deconditioning
- Depression
As Evidenced By:
- Forgetting Names or Dates
- Repeating Questions or Information
- Inability to Drive
- Inability to Recognize Friends or Family
- Need for Assistance with Self-Care
- Incontinence
- Disturbed Sleep Patterns
- Nonverbal Communication
- Agitation or Combativeness
- Paranoia
Expected Outcomes:
- Patient will maintain meaningful relationships as long as possible.
- Patient will seek social support through groups and community resources.
- Patient will maintain an active and enriched lifestyle within limitations.
Nursing Assessments:
- Support System Assessment: Assess for family, friends, and community support systems available for social interaction and assistance.
- Limitation Assessment: Determine physical and cognitive limitations impacting socialization.
- Mental Health Barrier Assessment: Assess for mental health barriers like depression, embarrassment, and hopelessness contributing to isolation.
Nursing Interventions:
- Cognitively Appropriate Activities: Provide games, activities, books, music, and exercise programs suitable for cognitive level. Encourage family involvement in hobbies and activities.
- Adult Daycare Referral: Refer to adult daycare centers or programs for socialization opportunities.
- Memory Reminiscence: Use music, photos, and questions about past experiences to stimulate memory and sense of identity.
- Outdoor Engagement: Encourage outdoor time in parks or natural settings for mood enhancement and social presence.
5. Risk for Falls
NANDA Diagnosis: Risk for Falls
This is a risk diagnosis pertinent to dementia patients due to cognitive impairment, mobility issues, and medication effects, all increasing fall risk.
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 (Sedatives, Antidepressants, Antipsychotics)
- Depression
- Caregiver Strain
Expected Outcomes:
- Patient will remain free from falls.
- Patient will correctly use assistive devices to prevent falls.
- Patient will call for assistance before ambulating or transferring.
Nursing Assessments:
- Fall Risk Assessment: Perform fall risk assessments using tools like the Morse Fall Scale, considering cognitive function scores (MMSE) as indicators of fall risk in dementia.
- Muscle Strength and Coordination Assessment: Assess gait, balance, motor skills, and assistive device use, noting that dementia patients may overestimate their abilities.
- Judgment and Perception Assessment: Regularly assess orientation and be aware of sundowning, which increases wandering and fall risk, particularly at night.
Nursing Interventions:
- Accessible Items: Keep frequently used items within easy reach to minimize movement.
- Fall Alert Devices: Utilize bed and chair alarms in hospitals and recommend personal fall alert devices for home use.
- Environmental Safety: Unclutter environment, remove hazards, and ensure clear walking paths.
- Visual Acuity Considerations: Address vision issues, use night lights, maximize daytime light, and use contrasting colors to improve visual perception and reduce confusion.
