Dementia
Protocol 10.1: Recognition and Management of Dementia (cont.)
3. Laboratory tests are valuable in differentiating irreversible from reversible forms of dementia. Structural neuroimaging with noncontrast computed tomography (CT) or magnetic resonance imaging (MRI) scans are appro- priate in the routine initial evaluation of patients with dementia.
F. Caregiver/Environment
The caregiver of the patient with dementia often has as many needs as the patient with dementia; therefore, a detailed assessment of the caregiver and the caregiving environment is essential.
1. Elicit the caregiver perspective of patient function and the level of support provided.
2. Evaluate the impact that the patient’s cognitive impairment and problem behaviors have on the caregiver (mastery, satisfaction, and burden). Two useful tools include the Zarit Burden Interview (ZBI) and the Caregiver Strain Index (CSI) tool.
3. Evaluate the caregiver’s experience and patient–caregiver relationship.
V. NURSING CARE STRATEGIES
The Progressively Lowered Stress Threshold (PLST) provides a framework for the nursing care of individuals with dementia.
A. Monitor the effectiveness and potential side effects of medications given to improve cognitive function or delay cognitive decline.
B. Provide appropriate cognitive enhancement techniques and social engagement.
C. Ensure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort measures.
D. Avoid the use of physical and pharmacological restraints.
E. Maximize functional capacity: maintain mobility and encourage independence as long as possible; provide graded assistance as needed with ADL and IADL;
provide scheduled toileting and prompted voiding to reduce urinary inconti- nence; encourage an exercise routine that expends energy and promotes fatigue at bedtime; and establish bedtime routine and rituals.
F. Address behavioral issues: identify environmental triggers, medical conditions, caregiver–patient conflict that may be causing the behavior; define the target symptom (i.e., agitation, aggression, wandering) and pharmacological (psycho- tropics) and nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect) approaches; provide reassurance; and refer to appropriate mental health care professionals as indicated.
G. Ensure a therapeutic and safe environment: provide an environment that is mod- estly stimulating, avoiding overstimulation that can cause agitation and increase confusion and understimulation that can cause sensory deprivation and with- drawal. Utilize patient identifiers (name tags), medic alert systems and bracelets, locks, and wander guard. Eliminate any environmental hazards and modify the environment to enhance safety. Provide environmental cues or sensory aids that facilitate cognition, and maintain consistency in caregivers and approaches.
H. Encourage and support advance care planning: explain trajectory of progressive dementia, treatment options, and advance directives.
(continued)
Protocol 10.1: Recognition and Management of Dementia (cont.)
I. Provide appropriate end-of-life care in terminal phase: provide comfort mea- sures including adequate pain management; weigh the benefits/risks of the use of aggressive treatment (e.g., tube feeding, antibiotic therapy).
J. Provide caregiver education and support: respect family systems/dynamics and avoid making judgments; encourage open dialogue, emphasize the patient’s residual strengths; provide access to experienced professionals; and teach care- givers the skills of caregiving.
K. Integrate community resources into the plan of care to meet the needs for patient and caregiver information; identify and facilitate both formal (e.g., Alzheimer’s association, respite care, specialized long-term care) and informal (e.g., churches, neighbors, extended family/friends) support systems.
VI. EVALUATION/ExPECTED OUTCOMES
A. Patient Outcomes: The patient remains as independent and functional in the environment of choice for as long as possible, the comorbid conditions the patient may experience are well managed, and the distressing symptoms that may occur at end of life are minimized or controlled adequately.
B. Caregiver Outcomes (lay and professional): Caregivers demonstrate effec- tive caregiving skills; verbalize satisfaction with caregiving; report minimal caregiver burden; are familiar with, have access to, and utilize available resources.
C. Institutional Outcomes: The institution reflects a safe and enabling environment for delivering care to individuals with progressive dementia; the quality improvement plan addresses high-risk problem-prone areas for individuals with dementia, such as falls and the use of restraints.
VII. FOLLOW UP TO MONITOR CONDITION
A. Follow-up appointments are regularly scheduled; frequency depends on the patient’s physical, mental, and emotional status and caregiver needs.
B. Determine the continued efficacy of pharmacological/nonpharmacological approaches to the care plan and modify as appropriate.
C. Identify and treat any underlying or contributing conditions.
D. Community resources for education and support are accessed and utilized by the patient and/or caregivers.
VIII. RELEVANT PRACTICE GUIDELINES
A. American Academy of Neurology: Detection of Dementia, Diagnosis of Dementia, Management of Dementia, and Encounter Kit for Dementia;
http://www.aan.com/go/practice/guidelines
B. American Association of Geriatric Psychiatry: Position Statement: Principles of Care for Patients With Dementia Resulting From Alzheimer Disease; http://
www.aagponline.org/prof/position_caredmnalz.asp
C. Alzheimer’s Foundation of America (AFA): Excellence in Care; http://www.
alzfdn.org
Protocol 10.1: Recognition and Management of Dementia (cont.)
ResOURces
Alzheimer’s Association http://www.alz.org
Alzheimer’s Disease Education and Referral Center http://www.alzheimers.nia.nih.gov
The National Family Caregiver’s Association (NFCA) http://www.nfcacares.org
American Association of Retired Persons (AARP) http://www.aarp.org/caregiving
ElderWeb
http://www.elderweb.com ConsultGeriRN
http://www.consultgerirn.org/resources Hartford Institute for Geriatric Nursing http://www.hartfordign.org/
National Conference of Gerontological Nurse Practitioners: Mental Health Toolkit http://www.ncgnp.org/
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