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COGNITIVE IMPAIRMENT (DEMENTIA

AND DELIRIUM)

HS3169 Adult Nursing 3

Care of the older adult
Lecture

Read: Brunner & Suddarths Textbook of

Medical-surgical Nursing (12th ed) pp. 213
220; 1986 1993.

Objectives
1. Define dementia.
2. Explore the prevalence of dementia in
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4.
5.
6.
7.
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Singapore.
Identify the types and causes of dementia.
Describe the symptoms of dementia.
Describe the management of dementia.
Define delirium.
Determine the causes of delirium.
Describe the management of delirium.

Definition of dementia
Dementia is the loss of mental functions, such as
thinking, memory, and reasoning, that is severe
enough to interfere with a person's daily life.
Dementia is not a disease itself, but rather a
group of symptoms that may accompany certain
diseases or conditions.
Symptoms may involve changes in personality,
mood, and behavior.

Prevalence of dementia
In Singapore, about 2% of people over the age
of 65 suffer from dementia.
Alzheimer Disease Association (Singapore).
A study estimates that the number of people with
dementia today is 30,000 and is projected to
increase as the population aged.
Unfortunately, there is generally a lack of proper
understanding of the symptoms or the burden that
both dementia patients and their caregivers have to
shoulder.

Singapore Statistics
Year
Prevalence
(000s)

2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
22

30

Year
Prevalence
(000s)

40

53

69

92

119

146

200 201 201 202 202 203 203 204 204 205
5 0 5 0 5 0 5 0 5 0
22 30 40 53 69 92 119 146 171 187

171

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Causes of dementia
Degenerative neurological diseases, including

Alzheimer's disease, Parkinson's disease,

Huntington's disease (a rare inherited disorder).
Vascular disorders, such as multi-infarct dementia,
which is caused by multiple strokes in the brain.
Traumatic brain injury caused by motor vehicle
accidents falls, etc.
Infections of the central nervous system such as
meningitis.
Chronic alcohol or drug use.

Causes of dementia cont.

Depression.
Certain types of hydrocephalus, an excess

accumulation of fluid in the brain that can result

from developmental abnormalities, infections,
injury, or brain tumors.
A study has shown a link between high blood
pressure and developing dementia. An
estimated 5% of those over the age of 65 have
dementia, rising to 20% over the age of 80.

Types of dementia
Dementia can be split into two broad categories

--based on which part of the brain is affected.

Cortical dementias arise from the cerebral
cortex, the outer layers of the brain that play a
critical role in thinking abilities like memory and
language. People with cortical dementia
typically show severe memory loss and aphasia
-- the inability to recall words and understand
language.

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Types of dementia
Subcortical dementias result from dysfunction

in the parts of the brain that are beneath the

cortex.. Victims of this disease are likely to show
changes in their personality and attention span,
and the slowing down of their thinking.
There are many cases of dementia where both
parts of the brain tend to be affected, such as
multi-infarct dementia.

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Alzheimers disease
Most common cause of dementia
Presence of neuritic plague containing deposits of

beta-amyloid protein in the brain.

Increased of beta-amyloid protein cause nerve cells to
die, neurofibrillary tangles in the cortex and
degeneration of neurons and synapses.
This results in cell damage and eventually cell death in
the parts of the brain that control memory, thought and
language.

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Plaques and Tangles

The formation of amyloid plaques and neurofibrillary tangles are thought

to contribute to the degradation of the neurons (nerve cells) in the brain
and the subsequent symptoms of Alzheimer's disease.

Brain With Alzheimer's

Disease

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The cross-section on the left represents a

normal brain and the one on the right
represents a brain with Alzheimer's
disease.

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Beta-amyloid protein in the brain.

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Stages of dementia
Early stage: Patient appears
forgetful or occasionally repeats
himself. Sometimes they behave
oddly and become withdrawn,
lethargic or agitated. Misplacing
things. Lack of motivation to work.

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Stages of dementia
Middle stage: In this stage, the changes become
more noticeable. The memory lapses are more
obvious. Behaviour becomes problematic and
may interfere with normal day-to-day activities.
Examples are wandering and getting lost,
repeating words, neglecting personal hygiene,
losing track of time and events, forgetting the
names of common objects and familiar people,
irritability and agitation, sundown syndrome
(increased behaviour problem after the sun goes
down).

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Stages of dementia
Late stage: Patient is unable to recognize

family members. Needs help in personal care

such as bathing, going to the bathroom,
dressing and eating. Speech may be difficult to
understand and may not comprehend what is
being said.

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Management of dementia
1. Reduce environmental confusion
Approach patient in a pleasant, calm way
Introduce yourself to the patient and greet her
Keep the environment simple and pleasing, remove all

unwanted utensils from the room.

Maintain a regular daily living schedule, so that the
patient will get touch with the daily living activities.
Provide memory device like, lists of activities, reminding
notes, labels on items; pictures, diagrams etc. will assist
the patient to remember.

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Management of dementia
2. Increased environmental cues (It will enhance orientation to time
place and person by filling memory gaps and serving as reminders)

Identify yourself when interacting with the patient

Address patient by name facilitate orientation to self
Offer environmental cues for orientation to time, place and

person
Bring the patient near the window and shows him the
surroundings
Interpret environmental stimulation as part of the
conversation (e.g. prior to switch on the light late in the
evening, tell the patient that the day is going to be over and
we need light, hence switch on the light)

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Management of dementia
3. Reduce anxiety provoking situations in daily routine
Keep reality orientation, non-threatening but acceptable to the patient (repeat
the answer if the patient asks again and again)

Be patience with forgetfulness

Maintain a daily, regular routine so that the client is able to recall the daily

activities

Simple structured stimuli are easiest to interpret (e.g. call the patient by name just
before lunch, tell him the exact time and about the lunch)

Be with the patient and listen to him what he/she actually wish to

communicate with you

Avoid situation that have upset patient in the past

Do not try to reason with the patient (Patient is unable to conduct abstract thinking)

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Management of dementia
4. Maintenance of a balance of sleep and activity
Reduce night-time distractions such as noise, nursing

procedures or midnight medications etc.

Take measurement to increase safety
Provide adequate night-lights
Enhance comfort if awake at night
Avoid use of restraints
Design a balanced schedule of activity / sleep
Increase daytime wakefulness and encourage short
rests than long time rest
Encourage regular exercise and activity programs to
mobilize joints (Daily activity and exercise reduce agitation and produce
soothening and a calming effect)

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Management of dementia
5. Maintenance of optimal level of nutrition
Monitor food intake and observe food habits
Note weight loss or gain
Provide regular mealtime schedule
Encourage adequate fluid intake
Provide balanced diet. If the client is unable to feed

himself, feed the patient; during feeding narrate short

stories which stimulate appetite as well as concentration
Maintain a calm and pleasant atmosphere
Offer a menu choice if possible
Offer familiar food (Pleasant mealtime if favourite and familiar food is
served, the client will eat well with enjoyment).

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Management of dementia
No cure for dementia unless the it is due

to some treatable underlying cause.

Prevention is the best.
Live an active life, both mentally and
physically and to manage stress well.
Medications which might contribute to
prevent the onset of dementia, including
hypertension medications to prevent
stroke, psychotic drugs, antidepressants
to prevent severe depression.

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Medication for dementia

Cholinesterase inhibitors- reduce the

enzymatic degradation of acetylcholine in

the synapse thus enhancing neuron to
neuron communication.
Ie Donepezil Cholinesterase inhibitors.

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Doll therapy and pet therapy

can help to calm disoriented
patients

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Managing difficult behaviour of dementia Alzheimer Disease Association (Singapore).

Do not expect the person to remember.

Dont say, Dont you remember?
When the victim becomes agitated try to distract

him/her with another activity.

Be flexible if the behaviour is not harmful to anyone
or himself/herself let if be.
Simplify activity as he/she will only be able to focus if it
is step by step.

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Managing difficult behaviour of dementia Alzheimer Disease Association (Singapore).

Create routine for daily activities to decrease anxiety.

Offer praise and reassure to reinforce good behaviour.

Use therapeutic communication.

Remove things that trigger off difficult behaviour.
Encourage caregiver to join support group to learn to
cope.

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Safety measures
1.Secure area with child-proof lock so that the person
cannot wander from the home.
2. Have the person wear identification
bracelet/lanyard or have information in
pocket/wallet. Include name, phone number of
caregiver, address and notation 'memory loss.'
3. Do not leave the person at home alone.
4. Secure the kitchen:
Keep flammable objects away.
Lock up knives.
Use safety latches on cupboards.

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Delirium
Delirium is a sudden or abrupt change

in cognitive functions and behaviour

(acute confusional state) characterized
by fluctuations in sensorium

Common geriatric syndrome affecting

the sick or frail older patients

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Clinical manifestations of delirium

Sudden onset
Disorientation
Drowsiness
Misinterpretations
Paranoid ideas
Hallucinations
Rambling incoherent speech
Restlessness, noisy/aggressive behaviour

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Causes of delirium in elderly

Brain disorder (tumor,

bleeding, stroke)
Post operative state
Constipation
Depression
Dehydration
Drugs
Hypoxia
Anaemia

Infection
Metabolic disorders
Renal and liver failure
Endocrine disorders
Untreated pain
Urinary retention
Vitamin B deficiency
Alcohol or drug

withdrawal

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Management of delirium
Delirium is treatable.
Determine the cause and treat it.
Drugs haloperidol if hallucinated or

paranoid.
Avoid restraint as much as possible.
Allay fear provide reassurance.
Provide a quiet and calm environment.
Keep the place and people familiar.
Do not change the bed position.
Engaged the help of family caregivers.

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How does delirium differs from dementia:

There are two main criteria:
1. Delirium occurs over a short period of time,
usually days or even hours whereas
dementia occurs over weeks, months, or
years.
2. Delirium lasts for a mere few days or weeks
while dementia is long lasting.

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Websites
http://www.alzheimers.org.sg/index.htm
http://www3.ntu.edu.sg/home2003/chew0012/cs227ada/
cs227ada/whatisdementia.html
http://www.medicinenet.com/alzheimers_disease/page8.htm
http://www.acadmed.org.my/cpg/Management_of_Dementia.pdf
Video:
Beloved Strangers Call No: RC523 BEL 25 min

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References
About Alzheimers. Alzheimers Disease Association. Singapore.
Retrieved from http://www.alzheimers.org.sg/index.htm
Eliopoulos, C. (2001). Gerontological nursing ( 5th ed.). Philadelphia:
Lippincott.
Hogstel, M. O. (2001). Gerontology nursing care of the older adult.
New York: Delmar Thomson Learning.
Wold, G. H. (2008). Basic geriatric nursing. St. Louis: Mosby.

Delirium or Dementia? Know the Symptoms