(This equals .1 CEU Credit for Iowa Nurses) This study was prepared by Linda S. Greenfield, RN, Ph.D.
Quality of life can be enhanced by quality care. This program emphasizes understanding and management approaches when caring for a patient with impaired cognition. It has been designed to help those healthcare workers who directly care for persons with dementia. It meets the requirements pursuant to s.400.4785(1)(a) and (b), Florida Statutes (F.S.)
Please read these IMPORTANT INSTRUCTIONS as they contain answers to many of the questions we are often asked regarding home study. If you have downloaded this course, you may save it to your hard drive or print all or any part of it. In this way the document is available to you as a resource. As you leaf through this study, you will notice that there are questions placed throughout the reading material. Please notice the last two pages and print these if you have downloaded the course. The first is an answer sheet. As you complete the study, record your answers on this sheet. A passing score of 75% must be achieved to receive credit. In the event that you do not reach 75% on the first submission, you may try a second time without paying again. You must pay again if you need more than two attempts to pass the course. You may refer to the material at any time and you may also study in groups, if you wish. The second sheet is an evaluation form and is to be filled out and submitted along with your answer sheet. If you find any errors, please note them so we may correct them at the next printing. You may submit your answers online and your certificate will be available upon successful completion. Or you may fax your answer sheet to 206-600-6268, or mail it to: Nurse Learning Center 8910 Miramar Pkwy Miramar, FL 33025. Faxed or mailed answer sheets are processed within one week of receipt. You receive credit on the date we process your answer sheet. If you put your fax number on the answer sheet, we will fax back a copy of your certificate before we put the corrected answer sheet and a certificate of completion in the mail to you.
If you have multiple professional licenses, we will record up to three license numbers on your certificate. For those in Florida, the license number, along with the initial letters of the number, is VERY IMPORTANT, as this is the mechanism used to report your hours to CE Broker. For example, #432152 would be unusable. RN432152 would be the correct license number for a registered nurse. NO SPACES in your license number. If this is for initial licensure, please indicate this situation in the license number space on the answer sheet. Should you decide not to finish the course this year, it can be applied anytime up to two years from the date of purchase.
Initial Printing: February 2002;
Current Revision: October 2009
TABLE OF CONTENTS
Course Instructions…………………………………….……… 2
Introduction and Objectives…………………………...………4
Brain Dysfunction in Dementia………………………………… 5
Diagnostic Tests……………………………………………… 8
Symptoms and Characteristics of Dementia…………………… 9
Reducing Anxiety-Producing Stimuli………………… 13
Increasing Sensory Input……………………………… 14
Verbal Communication………………………………… 15
Introduction and Objectives “I can’t get Rosie to bed,” complained the C.N.A. to the charge nurse. “Every time I get near, she threatens to hit me. I know what those skinny arms can do, and I’m not getting close.”
I looked up from my endless charting with a sigh. The C.N.A. was genuinely scared. But the bottom line remained that we had to try to get Rosie to settle down. The problem was that she seemed “wired tight” for the whole shift. While I suspected that her current drug regime was a factor to Rosie’s increasing anxiety, there were many other environmental factors as well. “Leave Rose until last,” I advised the aide, and I’ll try to get some extra time to help you with her, maybe in about 45 minutes. Does that sound workable?”
“Whatever,” the aide responded as she turned to return to work. “But it will take a miracle to get that lady settled down.”
Praying for just such a miracle, I returned to my charting, while my mind continued to rummage around for possible answers. There was so much to teach and so little time, yet it wasn’t fair to the aides to expect them to provide quality care when so little attention had been paid to giving them the guidance they needed to be safe, let alone be effective. It was all very frustrating. “But,” I thought, ”Imagine the frustration of being an aide and not knowing how you will ever get your work accomplished without being pounded to pieces. Imagine the frustration of wasting precious time with strategies that don’t work because no one took the time to teach you possible strategies that work better. Imagine the feelings of failure when you see others can do things with confused patients/residents that you can’t. Would you like to be treated like that?” I asked myself. “No way something has to give in this tight schedule. I need some time to help my aides,” I concluded, as I reluctantly grabbed the next chart awaiting my undivided attention, feeling chained to the chair and pen.
Rosie’s situation is not uncommon, and neither are the aide’s and nurse’s frustrations. Providing assistance with the tasks of daily living can be quite a challenge on some occasions, and the task certainly demands skill, patience, and as much understanding as you can get when communication skills are so badly impaired by disease. This course has the informational needs of the direct care workers in mind, regardless of the position of that person. It is created to help those standing at the bedside wondering how all of the required work can possibly be accomplished in one shift and still manage to be patient, caring, and make the day for the resident or client just a little brighter.
Objective No. 1: Distinguish between normal aging and memory loss from Alzheimer’s disease and related disorders.
Objective No. 2: Identify the characteristics of Alzheimer’s disease and related disorders.
Objective No. 3: Communicate effectively with residents who have Alzheimer’s disease and related disorders.
Brain Dysfunction in Dementia In the past, dementia was considered to be the obvious result of aging. It was what happened when you got old. But this is NOT true. Dementia is a disease that degenerates mental/emotional processes. A disease process has causes and treatments. The most common disease causing the confusion, memory loss, lack of judgment, etc., that we associate with dementia, is Alzheimer’s disease. Over half to three quarters of all the residents in all the nursing homes have a form of dementia. Of these, over half (50-68%) of the dementia is caused by Alzheimer’s disease. Seventy-five to eighty percent of the victims of Alzheimer’s disease are in their homes, supported by family caregivers. It is estimated that four to six million people in the US have Alzheimer’s disease. (Marin, 36, Cummings, 2263).
What do we know about Alzheimer’s disease? We are learning a lot, but as we learn, we discover how much more we need yet to learn. For example, Alzheimer’s has long been associated with neurofibrillary tangles. The fine filaments of the nerves in some parts of the brain where thinking and judgment are controlled, are tangled in clumps. But scientists have found neurofibrillary tangles to some extent in normal, non-psychotic, aged patients. The plaques associated with Alzheimer’s are also found, to a much less degree, in the normal aged brain. Some of the pathological changes seem to be a process of normal aging. The plaques and tangles are much more numerous in Alzheimer's patients. Tangles are also present in Parkinson's disease and in Down's syndrome.
Yet, the bottom line is that normal aging is not at all like dementia. People who are healthy and old can remember incredible details and think in very complex patterns. While they might process some things a little slower than they once did, when given that time, their judgment, logic, and ability to use language and do math, etc. is consistent with their total life span. While the adage is true, “if you don’t use it, you lose it”; it is true for all of us at any age. When non-diseased older people allow themselves to become “couch potatoes” with little mental stimulation, they will lose some of their skills. So will a younger person, although not as quickly.
We know more about how Alzheimer’s disease is different than normal aging. We know there are multiple imbalances in the chemicals that control nerve functioning in the brain, which disrupts other brain chemistry. Alzheimer's is a neuro-chemical disease. It is not a mental illness. Our world should not blame these individuals for their behavior, thinking they could change if they wanted. Intense reality orientation will not help. There is a chemical missing. Would you blame a diabetic for his wild behavior in hyperglycemia if you understood the behavior resulted from a deficiency of insulin? Neither would you blame an Alzheimer's patient for his wild behavior if you understood it resulted from a chemical deficiency that results in brain failure. The brain doesn’t function as it did before the disease.
Alzheimer's disease has become a catchall phrase for many elderly confused patients. In the same nursing home on the same day, I might chat with a 90 year old about the baby she says she had last night, or listen to another woman make senseless, loud noise off and on most of the day, or see a man talk to a mirror as if it were his best friend. The prevalent attitude today is that this is all caused by Alzheimer's disease. While this is true for the majority, much reversible dementia is being overlooked because of the attitude that all confusion is due to an irreversible pathology. It is estimated that 10% of patients with a diagnosis of Alzheimer's disease are found to have been misdiagnosed. There is a tremendous need to encourage the tests required to rule out the reversible causes and factors. Probably the most frequent cause of reversible confusion is toxic drug effect. The list of drugs that can create a confusion that looks like Alzheimer’s disease includes most of the drugs older patients receive. The real tragedy is some older persons are receiving drug therapy because they are confused, and the drug is making them more confused.
There are several diseases that are chronic and progress slowly, like Alzheimer’s disease, but they are not pathologically the same. These are called “related disorders.” Appendix 1at the end of the course has a list of other diseases that create dementia. Common symptoms include memory loss, aphasia (inability to use verbal communication), apraxia (inability to do things they used to be able to do, such as dress or eat, etc.), agnosia (inability to identify familiar objects like their fork or their bed, or even their children), and acalculia (inability to do math or tell time or count money.) But there are subtle differences. For example, Alzheimer’s is characterized by a gradual and progressive decline in function. Once a skill is gone it rarely returns, unless the decline is due to some reversible situation, such as drug effect. Another cause of dementia is called “Lewy body dementia”. With this dementia there is more fluctuation in the symptoms. They may have “good” days when they can do some things, and “bad” days when they seem totally lost. These fluctuations can vary from day to day, hour to hour. This is not typical in Alzheimer’s. Another cause called “vascular dementia” has more of a step-wise decline. Vascular dementia is most commonly associated with a series of small strokes. So, after a stroke, people function much lower, but then they stabilize at that level or might even improve slightly. With the next “mini-stroke”, they will be able to do less, but then will again stabilize at that newer, lower level. Vascular dementia has more motor systems, so they might have difficulty using one arm or have one-side weaker than the other.
You can understand the behaviors and symptoms of dementia better if you know more about how the brain works. The central nervous system is composed of the cerebral cortex, cerebellum, medulla and brainstem that connect with the spinal cord. For this study we only need to concentrate on the cerebral cortex as this is the part of the brain most acutely affected by dementias.
The cerebral cortex, as a whole, is a vast information storage area. Here is where memories are made and retrieved. Most of the senses and motor functions are at least interpreted here in the cerebral cortex and operations from other parts of the brain are coordinated with the cerebral cortex to get a complete interpetation, thought or action. If you will refer to the pictures of the brain on Appendix 2, you will see that the cerebral cortex is divided into lobes.
The prefrontal/frontal lobe controls thought. If the prefrontal area is damaged, as it is in Alzheimer’s, the patient can still think, but since a lot of memory and some of the mechanisms for processing the information are gone, the thought process may not seem logical to others. Think for a moment about how important memories are. Memories allow us to recognize anything -- even the words on this page. Memories tell us what is good and bad, who we are, and what our existence is. Our lives are our memories. How we have learned to relate to other people are memories. If a section of our brain that retrieves and uses memories is damaged and does not work well, the effects on our lives are devastating. However, the storage of memories is still poorly understood. Although there is drastic memory loss in advancing Alzheimer's disease, not all memory is lost. Memories for the need for affection, friendships, likes and dislikes, etc. continue, although changed. Even throughout dementia a person's experience continues to influence the way he feels about himself and his social environment and will affect his sense of worth, happiness and aspirations.
A person with prefrontal loss is easily distracted and can't keep a thought pattern for long. This part of the brain keeps mental functions directed toward a certain goal. Damage to this area causes the goal to be lost, and attention span to be short. For example, it is difficult to encourage a demented person to sit at the table long enough to finish a meal. But, on the other hand, it is easy to divert his attention when necessary. The 45 minutes that the nurse asked for in the beginning scenario, would be a helpful break because Rosie would forget her previous encounter when the aide had tried to put her to bed earlier. Rosie would be in a completely different state of mind by the time they tried again and probably would have no memory of what had happened already that evening.
Another interesting facet to the loss of the prefrontal/frontal area is the loss of morals. Morality is a very complex, abstract thought process. Morality is also memories. I watched a mother teach her young toddler that it was inappropriate to take off her clothes when she was outside playing on a hot summer day. This child was not born with morality. Each time her mother found her without proper dress, she inflicted a memory into the child's brain to teach her appropriate social behavior. With enough memories the child learned to wear clothes. If her memories could no longer be utilized by her brain, why should she want to wear clothes in very hot weather? A person with memory loss from prefrontal damage will not be embarrassed by sexual, personal, bladder/bowel, or social activities that may be inappropriate.
This person may also quickly change his mood from happy to depressed; from angry to docile. Our emotions and moods are a result of our memories and how we perceive our environment. We often hear, "He would never do that if he were himself". And that is true. His behavior was dictated by his life and the programming he received from childhood on. All of this programming was stored in his memory bank and the prefrontal area used these memories, with abstract thought and input from the emotional system, to control behavior patterns. Now, the prefrontal area is damaged and much of the memory is gone. Consequently, his behavior and emotions are different than in the past, and not consistent from day to day. With more complicated diseases, such as Alzheimer's, there are few new memories being made to dictate behavior in the future.
The parietal lobe largely deals with sensations and spatial organization. For example, a person with parietal damage may not know where his hand is. He can look at it, but he may not recognize it as his. He may feel an object is touching his skin, but he cannot distinguish the shape of the object or just where it is touching him. His brain cannot interpret the sensation of touch. Spatial relationships are not organized when there is parietal damage. If you ask an Alzheimer's patient to draw a clock, he may get all the numbers in the clock face, but cannot put the numbers in relationship to each other. Neither can he tell time. He'll get lost easily. Imagine how frightening it must be to perceive the environment with little organization! Imagine what happens to his orientation when you turn him around in a wheelchair and pull him backwards into a bathroom for his bath. This “lost in space” feeling creates great anxiety and he’ll be climbing the walls before you even get the water turned on.
The temporal lobe and the occipital lobe also assist with the senses, particularly the interpretation of the information coming from the ears (temporal) and the eyes (occipital). Damage causes an error in interpretation. For example, he can hear, but may not be able to understand what he hears. He can see, but he can't always interpret what he sees, and may not recognize familiar objects. The resident may see a coat hanging on a rack, and go up to it and talk to it as if it were a person. Mirrors, TVs, radios all cause confusion because they can’t recognize what they are seeing or hearing. The variety of symptoms that come from misinterpreting sounds and sights are numerous and usually frustrating because the individual believes what his brain is telling him, and his brain has minimal memories, so his guesses are often wrong. Regardless, he will usually still trust his own interpretations, rather than easily accept those of another person. A nightlight behind the chair is thought to be a fire in the room. The nursing assistant is thought to be the patient’s daughter, but the real daughter is thought to be a stranger. A bundle of bed covers is thought to be a baby. I’m sure you can add your own list of ways things are mis-interpreted.
Finally, the hippocampus is necessary for long-term memory. The hippocampus seems to act as a sorting station for memories -- retrieving those necessary for thought and storing others until needed later. Some long-term memories that existed before the damage might still be intact but short-term events cannot be transferred into long-term memory storage. This person cannot learn or learns very slowly. The hippocampus is an area of extensive research in Alzheimer's disease.
Diagnostic Tests A complete examination is necessary if dementia is suspected or if the cause of confusion cannot immediately be found. Hospitalization is not required to complete these studies and the tests can be completed over many days to allow the person adequate rest, and mental and emotional recovery between tests. A typical dementia workup includes:
--Magnetic Resonance Imaging (MRI) is often used instead of a CAT scan.
--PET scans reveals even early dysfunctions in dementias and is still considered the most reliable scanning technique. It shows decreases in sugar metabolism in the temporal and parietal lobes.
--SPECT Scans are becoming more readily available and are far less expensive than the PET scan. It shows blood perfusion in the brain. SPECT is quickly becoming the scan of choice for dementia.
--Lumbar Puncture. There are metabolites and other chemicals in the spinal fluid that can indicate early dementia.
--Neuropsychological tests of mental and physical capabilities. These test intelligence, language, memory, attention, motor and sensory function, praxis, behavioral and personality variables, etc.
--Psychiatric consult, especially if depression is evident.
In addition, there are batteries of assessment tools to measure functional abilities. Although the diagnostic batteries are longer and more sophisticated, many have been altered to allow bedside assessment and monitoring. Accurate diagnosing is important, but it is difficult. Families and patients are most disappointed to learn that after all the cost and energy, the diagnosis will not be definite. For most dementias, diagnosis is a matter of ruling out all possible causes. The specific type cannot usually be definitely determined until autopsy. Families will be encouraged to know that the course of most dementias is usually prolonged and there can be reasonable quality of life during much of the early years. Not every patient has every problem associated with these diseases, and some people have a rather mild course.