COGNITIVE IMPAIRMENT (DEMENTIA) in OLDER

(1)

COGNITIVE

IMPAIRMENT

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Learning Objectives

 _{Terminology for cognitive impairment}

 _{Theories about dementia}

 _{Risk Factors}

 _{Nursing Care Plan}

(3)

Dementia

 _{Considered as a syndrome, not a diagnosis}

 _{Persistent change in cognitive function occurs,}

with memory loss, and at least one other type of cognitive deficit (Ebersole, 2005)

 _{Progressive, multifocal cognitive decline that}

impairs daily activities (Volicer&Hurley, 1998)

 _{Persistent decline in two or more acquired}

intellectual function in the presence of a stable level of consciousness.

(4)

Dementia is not a specific disorder or disease. It is a syndrome (group of

symptoms) associated with a progressive loss of memory and other intellectual

functions that is serious enough to interfere with performing the tasks of daily life.

Dementia can occur to anyone at any age from an injury or from oxygen deprivation, although it is most commonly associated with aging. It is the leading cause of

institutionalization of older adults. (http://www.minddisorders.com/Del-Fi/Dementia.html)

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Fact of Dementia

 _{five million people in the United States}

have some degree of intellectual

impairment; further, 7–8% of them have a severe cognitive impairment (Mace & Rabins 2006).

 _{7.63% of Japanese people over 65 years}

of age suffer from dementia (Kouseikai Medical Corporation 2007)

(6)

Types of Dementia

 _{Primary (Progressive dementias):}

Caused by brain pathological conditions

 _{Secondary Dementias: Produced brain}

pathological conditions as a result of other condition

 _{Mixed Dementias: Produced by a}

combination of primary and secondary causes

(7)

Primary and Secondary Dementias

Primary

 _{Alzheimer's disease/}

AD (50-60%)

 _{Diffuse Lewy Body}

Dementia/ DLBD (15-25%)  _{Vascular dementia/} VaD (10%)  _{Pick's disease}  _{Huntington's disease}  _{Creutzfeldt-Jakob} disease Secondary  _{Alcohol-associated} dementia  _Parkinson`s associated dementia  _HIV  _{Poststroke dementia}  _Postanoxic encephalopathy

(8)

Alzheimer's Disease

 _{Cerebral degenerative disorder of}

unknown origin

 _{Destroy proteins of nerve cells of the}

cerebral cortex diffuse infiltration with nonfunctional tissue

 _{The course of AD ranges from 1 to 15}

years; typical life expectancy is 8 to 9 years after symptom onset

 _{Death usually occurring as a result of}

pulmonary infections, UTI, Pressure ulcer and iatrogenic disease

(9)

(10)

Clinical Features of Dementia

(at least one)

 _{Aphasia: Loss of ability to speak with relevance}

and fluency

 _{Apraxia: Inability to carry out purposeful}

movements although motor and sensory abilities are intact

 _{Agnosia: Inability to recognize common objects}

or faces of familiar people despite intact sensory abilities

 _{Disturbances in executive functioning (planning,}

(11)

Pengkajian

Terdapat :

 _{Tingkat penurunan kognitif}

 _{Kemunduran kemampuan untuk}

ekspresikan pikiran dalam tulisan

 _{Orientasi terhadap orang, waktu dan}

(12)

Pengkajian

 _{Penurunan kemampuan dalam}

mengambil keputusan

 _{Penurunan kemampuan}

komunikasi/bicara

 _{Penurunan kemampuan ADL}

 _{Penurunan penampilan secara}

(13)

Pengkajian

 _{Penurunan berat badan/status nutrisi}

 _{Perubahan pola tidur}

(14)

Analisis

Contoh masalah dimensia

Nutrisi/cairan: kurang dari kebutuhan

Gangguan proses pikir

(15)

Diagnosa Keperawatan

Contoh

1. Gangguan proses pikir b.d. kemunduran/ kerusakan

memori sekunder dari dimensia

2. Resiko melakukan kekerasan b.d. agitasi atau agresif 3. Resiko nutrisi/cairan kurang dari kebutuhan tubuh b.d.

gangguan proses pikir

4. Resiko membebani keluarga b.d. ketergantungan dalam

aktifitas sehari-hari

(16)

Rencana Keperawatan

Dx 1 :

Tupan: Setelah dilakukan intervensi 12 pekan berturut-turut gangguan proses pikir dapat diatasi/ diadaptasi melalui tupen

Tupen: Setelah dilakukan intervensi 2 x sepekan kemampuan daya ingat klien meningkat:

 Dapat menyebutkan nama ners yang merawat  Menyebutkan kata sederhana yang dijelaskan  Menyebutkan nama hari dan bulan

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Rencana Keperawatan

Rencana Intervensi:

1. Beri arahan yang jelas dan sederhana, tahap

demi tahap, satu untuk satu waktu

2. Beri instruksi sesuai dengan kapasitas klien

3. Ingatkan secara verbal apabila klien lupa

melakukan sesuatu yang harus dilakukan

4. Berikan pernyataan mendukung/empati jika

klien sulit mengingat sesuatu dan stimulasi untuk mengingat

(18)

Rencana Keperawatan

1. Lakukan hal-hal yang rutin sesuai jadwal yang disepakati 2. Stimulasi klien untuk mengingat dengan menggunakan

alat bantu misalnya kalender dengan angka yang besar-besar untuk menstimulasi klien mengingat hari dan bulan

3. Dorong klien untuk menggunakan jam meja untuk

mengingat waktu

4. Diskusikan dengan klien tentang pengalaman yang

menggembirakan dan berikan pujian atas kemampuan mengingat klien

(19)

Bentuk Intervensi pada

Gangguan Kognitif

1. Stimulasi Kognitif

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Stimulasi Kognitif

Tujuan :

Memberikan rangsangan pada SSP

khususnya fluid intelligence agar daya

ingat dapat dipertahankan seoptimal mungkin

Persiapan alat:

1.Kalender dengan angka yang besar

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Stimulasi Kognitif

Proses:

1. Anjurkan klien duduk dan letakkan alat peraga

didepannya dengan jarak pandang yang jelas, gunakan kaca mata bila perlu

2. Anjurkan klien menyebutkan apa yang ditunjuk ners 3. Tutup alat peraga selama 5 menit, minta klien untuk

mengulangi kembali

4. Latih secara teratur 15-20 menit sehari agar dapat

mempertahankan tingkat daya ingat klien dengan melibatkan keluarga untuk membantu

(22)

Stimulasi Kognitif

Hasil:

1. Evaluasi respon verbal dan non verbal

klien apa yang klien rasakan terhadap latihan yang diberikan

2. Anjurkan klien mengulangi 15-20 menit

(23)

Stimulasi Perspektif

Tujuan :

Memberikan rangsangan kepada SSP khususnya fluid intelligence agar tidak terjadi distorsi persepsi klien

terhadap objek atau benda terkait dengan kemunduran emosi dan intelektualnya

Persiapan alat:

1.Gambar-gambar pemandangan

(24)

Stimulasi Perspektif

Proses:

1. Anjurkan klien duduk dan letakkan alat peraga

didepannya dengan jarak pandang yang jelas, gunakan kaca mata bila perlu

2. Anjurkan klien menyebutkan atau menuliskan apa

yang ditunjuk ners

3. Minta klien untuk menceritakan kembali apa yang

dilihat

4. Bandingkan dengan persepsi ners atau keluarga.

Apakah ditemukan penyimpangan? Jika ya, gali apa yang melatarbelakangi dan intervensi

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Stimulasi Perspektif

Hasil:

1. Evaluasi respon verbal dan non verbal

klien terhadap latihan yang diberikan

2. Anjurkan keluarga untuk mengulangi

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Implementasi

1. Gunakan bahasa sederhana yang mudah

dipahami

2. Gunakan teknik komunikasi terapeutik: tatap

muka, sentuhan, teknik fokus, refleksi, klarifikasi, dst

3. Berikan kesempatan pada klien untuk

mencerna informasi yang disampaikan

4. Gunakan alat bantu yang memudahkan klien

(27)

Evaluasi

 _{Observasi dan catat semua penampilan dan}

kemampuan klie selama dan setelah intervensi

 _{Bandingkan dengan tupen yang telah ditetapkan}

 _{Susun rencana tindak lanjut terhadap perilaku}

yang belum icapai sesuai tupen

 _{Cermati perubahan/kemunduran kognitif yang}

(28)

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Impairment Level and CDR Score (0, 0.5, 1, 2, 3)

None

0 Questionable0.5 Mild 1 Moderate2 Severe3 Memory No memory loss or

slight inconsistent forgetfulness Consistent slight forgetfulness; partial recollection of events; "benign" forgetfulness

Moderate memory loss; more marked for recent events; defect

interferes with everyday activities

Severe memory loss; only highly learned material retained; new material rapidly lost

Severe memory loss; only fragments remain

Orientation Fully oriented Fully oriented except for slight difficulty with time relationships

Moderate difficulty with time relationships; oriented for place at examination; may have geographic

disorientation elsewhere

Severe difficulty with time relationships; usually disoriented to time, often to place

Oriented to person only

Judgment & Problem

Solving

Solves everyday problems & handles business & financial affairs well; judgment good in relation to past performance Slight impairment in solving problems, similarities, and differences Moderate difficulty in handling problems, similarities, and differences; social judgment usually maintained Severely impaired in handling problems, similarities, and differences; social judgment usually impaired Unable to make judgments or solve problems Community

Affairs Independent function at usual level in job, shopping, volunteer and social groups

Slight impairment in

these activities Unable to function independently at these activities although may still be engaged in some; appears normal to casual inspection

No pretense of independent function outside home

Appears well enough to taken to functions outside a family home

No pretense of independent function outside home

Appears too ill to be be taken to functions outside a family home

Home and

Hobbies Life at home, hobbies, and intellectual interests well

maintained

Life at home, hobbies, and intellectual interests slightly impaired

Mild but definite impairment of function at home; more difficult chores abandoned; more complicated hobbies and interests abandoned

Only simple chores preserved; very restricted interests, poorly maintained

No significant function in home