These opening lines of “Forgetfulness,”¹ a poem by U.S. Poet Laureate Billy Collins, may elicit a rueful chuckle from the middle-aged or elderly person struggling with intermittent memory lapses, but worry and fear may lie just beneath the surface. As people laugh over their own “senior moments,” they may be feeling genuine concern about aging family members with more serious lapses.

Like the general public, nurses may misunderstand confusion in the elderly. While not deliberate, ageism and stereotyping exist and can have a significant impact on recognition of memory problems in seniors. How often have you heard, or perhaps thought yourself, “What do you expect from someone that old?” when an elder manifests confusion or memory problems?

Given current population statistics, it makes sense that dementia in the elderly is rapidly becoming a major social issue. Resources are diminishing, while the elderly population is growing by nearly one million a year, an increase projected to continue for the next 20 years.² Approximately 1.8 million Americans have severe dementia, and an additional one million to five million Americans have dementia ranging from mild to moderate. Approximately four million of those suffering from dementia have Alzheimer’s disease (AD). According to the U.S. Census Bureau’s projections on aging, by the year 2040, the number of persons with AD could grow to more than six million.³

Caring for the elderly patient with dementia requires a strong knowledge of senior health issues and resources, and excellent team skills. Today’s nurse faces unprecedented challenges in providing compassionate care with a focus on patient quality of life, while juggling a heavily regulated system and dealing with reductions in staff and resources. In the meantime, the numbers show that the largest consumers of healthcare are those 85 years and older.⁴

Dementia and delirium: defining differences

Changes in cognition may appear rapidly or take a slower, subtler path. For example, delirium, a serious acute medical condition, is not the same as dementia and requires a different response. Presenting as a sudden change in mental status, delirium is characterized by disorganized thinking, disorientation, reduced level of attention, drowsiness, apathy, or agitation. Approximately 25% of elderly patients admitted to a hospital develop delirium, and those with dementia are at higher risk.⁵ Any number of medical conditions can lead to delirium; infection, drug toxicity, hypoglycemia, dehydration, and alcohol top the list of many possible causes. An unfamiliar environment, sensory overload, sleep deprivation, and hearing or visual impairment can also contribute to development of delirium in an elderly patient. Because of their difficulty or inability to compensate for the multiple physiological and psychological stressors brought on by illness, older adults may rapidly develop symptoms of delirium. As a medical emergency, it requires immediate treatment.

In contrast to delirium, dementia is a syndrome characterized by generalized cognitive deterioration. Dementia results in changes of behavior, perception, memory, problem-solving abilities, and judgment that interfere with normal daily routines and functions. Dementia may be reversible or irreversible, although many illnesses with a dementia component are progressive and fatal. In the elderly, dementia is a complicated health issue because it has multiple causes, presents in many different ways, is difficult to recognize, and varies in duration.

The American Psychiatric Association lists several definitions of dementia, each associated with a specific cause. However, all patients with dementias exhibit the following multiple cognitive deficits that include —

1. Memory impairment
2. At least one of the following cognitive deficits:

• Aphasia (a deficit or loss of language function in which the comprehension or expression of words is impaired)
• Apraxia (loss or impairment of the ability to execute complex coordinated movements without impairment of the muscles or senses)
• Agnosia (failure to recognize familiar objects, people, or places)
• Inability to carry out higher level functions, such as shopping, cooking, or paying bills.⁶

It is normal for the elderly to have some decline in memory and to learn new information more slowly. This, however, should not be confused with dementia. The normal cognitive decline associated with aging occurs at different rates and is limited mainly to subtle changes in memory and a decreased rate of information processing. These changes are not progressive and do not affect someone’s ability to live independently.

Mild cognitive impairment (MCI) is a condition of moderate memory impairment without the associated problems that interfere with daily functioning. The literature describes it as a stage between normal cognition and dementia. Patients may benefit from early identification of MCI, since studies suggest those with MCI may be at greater risk for developing AD.⁷

Many causes of dementia

There are many conditions that lead to dementia. AD is the most common, accounting for more than 60% of all cases.⁸ Dementia caused by AD is irreversible. It has an insidious onset, gradual progression, and is fatal, usually within eight years to 10 years from onset, but may be present much longer. In AD, changes in the brain's structures occur with the formation of plaques, tangles, and neuronal loss. Although the cause is unknown, scientists speculate that genetic predisposition,⁹ head injuries, viruses, and toxins may predispose an individual to disease development.¹⁰ While definitive diagnosis of AD is possible only during an examination of brain tissue on autopsy, researchers continue to explore ways to detect AD in its earlier stages. Use of Positron Emission Tomography (PET) scans and evaluations of spinal fluid for AD-specific proteins are just some of the AD diagnostic strategies that are being studied.¹¹ Currently, medical and genetic research offers hope for prevention, delay of symptoms, effective pharmacological management with newer medications, and the potential development of a vaccine.¹² Stem cell research holds some promise but, according to the Alzheimer’s Association, is not broadly viewed as a viable source of solutions at present.

Vascular dementia is another leading cause of dementing illness and can occur as “mixed dementia,” in combination with AD.¹³ Vascular dementia results from vascular disease or infarcts in cerebral blood vessels.⁸ Atherosclerosis, cardiovascular disease, hypertension, and atrial fibrillation are risk factors for development of vascular dementia. Because infarcts vary in size, location, and frequency, symptom onset can be abrupt or subtle. Stepwise deterioration of cognitive function occurs with plateaus and occasional episodes of improvement.

Parkinson’s disease, multiple sclerosis, Fronto-Temporal dementia/Pick’s disease, Down Syndrome, Creutzfeldt-Jakob disease, Wernicke-Korsakoff syndrome, Normal Pressure Hydrocephalus (NPH), Huntington’s chorea, Lewy body dementia, and AIDS are some of the other conditions or diseases that cause symptoms of a progressive dementia.

There are some reversible illnesses, which cause dementia-like symptoms. With appropriate identification and treatment, cognitive impairment caused by depression, metabolic disorders, drug interactions, or combinations of illnesses may improve. Other possible reversible causes are vitamin or hormone deficiencies, including vitamin B12 deficiency and hypothyroidism; and bacterial or viral infections, such as encephalitis, syphilis, or meningitis.

Identifying dementia

Many patients with dementia do not visit their health care providers with a complaint of memory loss or cognitive deterioration. Although sufferers may notice memory problems, they often do not associate them with a serious medical condition. Fear and the stigma associated with dementia often lead people to conceal symptoms of cognitive impairment. Others may just believe memory loss is something to be expected with aging.

Identification of dementia usually begins with the recognition of “behavioral triggers” or “triggering events.” Often the patient’s spouse, good friend, or relative brings the problem to the practitioner’s attention. In fact, memory impairment may exist for months, a year, or longer before visiting a provider, and then it may be possibly precipitated by a crisis. Frequently, patients and families report the patient’s inability to fully engage in routine communication, interactions, or daily tasks as early observable signs of memory impairment. The behaviors may occur alone or in combination, and may be apparent at any point in the course of a dementing illness. The behaviors are listed in the sidebar.

Comprehensive geriatric assessment

Screening for dementia involves close observation and thorough history taking. To collect information and gain insight into symptoms and problems, health care providers often must include those closely associated with the patient in the assessment process. Once it is determined that an elderly person may be showing signs of dementia, the provider must complete a thorough history and physical examination to rule out an acute problem or otherwise correctable condition. The medication review must include over-the-counter medications. Medication interaction and overuse can be significant, but reversible causes of a change in mental status.¹⁴

Neurologic status, physical function, cognition, and mood are other components that must be examined when evaluating dementia. A referral for a neuropsychiatric evaluation is often recommended. The Mini-Mental Status Exam (MMSE) is a frequently used tool to assess cognition. The MMSE uses a scoring system to gauge orientation, attention, short-term and long-term memory, language, and motor skills.^8,15 A screening for depression is also indicated when symptoms of dementia are present. Depression in the elderly can present with symptoms of cognitive impairment, and, when the depression is treated, cognition may improve. Conversely, many patients with dementia also suffer from depression.

Finally, laboratory and radiological testing may be indicated to rule out medical causes of symptoms. Commonly ordered tests include CBC, B12, liver, kidney, and thyroid function studies. A computed tomography (CT) scan or magnetic resonance imaging (MRI) may also be ordered.

Medical management

Acetylcholine (ACh) and glutamate are both neurotransmitters associated with AD, but they have differing mechanisms of action. Because decreased ACh production has been implicated in AD, pharmacological treatment is directed at inhibiting those enzymes that break down and destroy ACh. The FDA has approved five medications for the treatment of AD. Of these, four enhance ACh function through the use of acetylcholinesterace inhibitors — tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl). The fifth FDA-approved drug to treat AD, memantine (Namenda), offers neuroprotective effects by blocking excess glutamate, which is released in excess amounts by nerve cells damaged by AD, resulting in further cellular degeneration.¹⁶ These medications are effective for limited amounts of time, and while they delay and slow the progression of the disease, they do not reverse damage.¹⁷ GI complaints are common adverse effects of these drugs and may be the reason for discontinuation of therapy.

In addition to the above medications, many physicians use a variety of other drugs and vitamins with the hope of preventing or delaying the progression of this devastating disease. Antioxidants such as vitamin E, cholesterol lowering statin drugs, hormone replacement therapy (HRT) in women, and anti-inflammatory agents also have been considered as treatment modalities.

To manage dementias other than AD, clinicians treat the causative pathology. For example, the use of anticoagulants for patients with atrial fibrillation and treatment of hypertension, with appropriate drug therapy may prevent or slow the progression of vascular dementias. Treatment may also include medications to ease behavioral and emotional symptoms. Antipsychotics, anxiolytics, and antidepressants are prescribed individually or in combination to manage psychiatric pathology coexisting with a dementing illness.¹⁸

Although many studies have shown possible or actual benefits with the use of medications and treatments for dementia, studies with conflicting data continue to surface. For example, vitamin E has been shown to slow the progression of AD.¹⁵ However, a recent study suggests increased death rates of patients who receive too high doses, or take vitamin E in combination with anticoagulants.^19,20 Studies have also shown that estrogen therapy in postmenopausal women may prevent or delay onset of AD, but it has not been shown to improve cognitive function or delay progression of the disease.²¹ More disturbing was another major study that showed that women who began taking HRT at age 65 or later had twice the rate of dementia compared to those who did not.²²

Given the complexity of human biochemistry, it is critical that practitioners continuously check ongoing research for updates to dosages, interactions, and contraindications of all treatments. Discussion between practitioner, patients, and caregivers can mitigate risks.

Nursing interventions

The goal of treatment is to maintain function and quality of life. This is achieved through behavioral, environmental, and medical management, as well as social and emotional support. A multidisciplinary team approach to assessment and care aids in the optimal management of dementia. The team members include the primary care physician, geriatrician, nurse practitioner, psychiatrist, neurologist, geriatric nurse, social worker, physical therapist, occupational therapist, dietitian, and, most important, the patient and family.

Nurses play an important role in overall management and care through coordination of services, education, and modeling the best methods of treatment and care. When they coordinate services for memory-impaired patients, nurses find that it’s best to focus on abilities rather than disabilities.

Guidelines for care include —

• To preserve function, encourage patients to do what they can for themselves.
• Provide familiar and simplified routines.
• Offer visual and verbal cues.
• Present opportunities for activities and socialization appropriate to cognitive levels.
• Plan care with a focus on safety and function.
• Provide support to caregivers.

Care based on an individual’s cognitive level will enhance self-efficacy, self-esteem, and overall dignity. Activities should be structured to minimize problems and create a positive, stimulating, and nurturing environment that honors each person’s uniqueness and values.

In addition to attending to the needs of the patient with dementia, the nurse must be cognizant of the role the family plays in caregiving. Caring for someone with dementia offers tremendous rewards and significant challenges, and the effects of caregiver stress are well documented. A study on caregiver well-being explored the differences between caregivers of those with dementing illness versus caregivers of those without dementia. The researchers found that “dementia caregivers” spent more hours per week providing care than those caring for patients without dementia. Also, a significant number of dementia caregivers reported making serious employment changes because of their responsibilities, such as retiring early, taking less demanding jobs, declining promotions, and giving up work entirely.²³

Families and health care providers often face ethical dilemmas and difficult decision-making situations in which they must select solutions from a list of options, none of which are appealing. Respecting autonomy while attempting to develop a safe plan of care for those with varying stages of cognitive impairment presents special challenges.

Often, care strategies are initiated on a trial-and-error basis because of the unpredictable nature of responses from patients with an impaired ability to understand and communicate.

Meeting the needs of the entire household is an important consideration in the planning process, and this includes providing resource information for both the caregiver and patient. General information related to dementia includes providing an explanation of dementia; behavior management strategies; caregiver support group information; strategies to address safety concerns; and information on legal and financial issues, including advance directives and appointing medical and financial power of attorney. Acknowledging and respecting cognitively impaired patients as adults is fundamental in building a constructive caregiver relationship. Cognitively impaired adults retain their adult self-image even into later stages of dementing illness and need to be included as much as possible in planning care routines, activities, and other factors that impact their lives.²⁴ Working to establish a trustful relationship with all involved helps patients and caregivers achieve maximum independence and functional capabilities.

Quality of life and dignity

Dementing illnesses are complicated, and patients benefit from a multidisciplinary approach to treatment and care. Health care providers must explore new ways to optimize care to meet challenges of caring for those living with dementia. Optimal individualized care planning calls for creativity, flexibility, and an objective strengths-based approach. What may seem unorthodox or unusual may be just the right intervention in terms of preference and acceptance. Nurses can help patients and families maintain quality of life and dignity by understanding and respecting the fundamental emotional, spiritual, and physical needs of everyone involved.

Communication of hope is important to dispel some of the fears associated with memory impairment. Despite many losses, people often continue to find enjoyment in life, and nurses can point this out to caregivers in times of discouragement and continue to explore resources in every situation. Respect and inclusion of the patient are paramount. A patient’s sense of control over decision making and planning helps to ease the anxiety associated with receiving a diagnosis of a dementing illness. As an advocate for quality of life and a guardian of dignity, the nurse is often the health care professional who sees a patient and family through the ups and downs of daily life with dementia — an awesome responsibility and privilege.