Nursing Standard of Practice Protocol: Recognition and Management of Dementia
Kathleen Fletcher, RN, MSN, APRN-BC, GNP, FAAN
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.
The information in this "In depth" section is organized according to the following major components of the NURSING PROCESS:
Parameters of Assessment
Nursing Care Strategies
Follow-up to Monitor Condititon
Relevant Practice Guidelines
A. Early recognition of dementing illness.
B. Appropriate management strategies in care of individuals with dementia.
The rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. It is imperative that a differential diagnosis be ascertained early in the course of cognitive impairment and that the patient is closely monitored for coexisting morbidities. Nurses have a central role in assessment and management of individuals with progressive dementia.
1. Dementia is a clinical syndrome of cognitive deficits that involves both memory impairments and a disturbance in at least one other area of cognition such as aphasia, apraxia, agnosia, and disturbance in executive functioning.
2. In addition to disruptions in cognition, dementias are commonly associated with changes in function and behavior.
3. The most common forms of progressive dementia are Alzheimer's disease (AD), vascular dementia, and dementia with Lewy bodies; the pathophysiology for each is poorly understood.
4. Differential diagnosis of dementing conditions is complicated by the fact that concurrent disease states (i.e., comorbidities) often coexist.
1. Dementia affects about 5% of individuals 65 and older.
2. Four to five million Americans have AD.
3. Fourteen million are projected to have AD by the year 2040.
4. Global prevalence of dementia is about 24.3 million, with 6 million new cases every year.
C. Risk Factors
1. Advanced age
2. Mild cognitive impairment
3. Cardiovascular disease
4. Genetics: family history of dementia, Parkinson's disease, cardiovascular disease, stroke, presence of ApoE4 allele on chromosome 19
5. Environment: head injury, alcohol abuse
Parameters of Assessment
No formal recommendations for cognitive screening are indicated in asymptomatic individuals. Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia and dementia-like presentation in early stages. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment.
A. Cognitive Parameters
1. Orientation: person, place, time
2. Memory: ability to register, retain, recall information
3. Attention: ability to attend and concentrate on stimuli
4. Thinking: ability to organize and communicate ideas
5. Language: ability to receive and express a message
6. Praxis: ability to direct and coordinate movements
7. Executive function: ability to abstract, plan, sequence, and use feedback to guide performance
B. Mental Status Screening Tools
1. Folstein Mini-Mental State Examination is the most commonly used test to assess serial cognitive change. On average, the MMSE declines 3 points per year in those with AD. The MMSE is copyrighted and a comparable tool called the St. Louis Medical Status (SLUMS) Examination is in the public domain.
2. Clock Drawing Test (CDT) is a useful measure of cognitive function that correlates with executive-control functions.
3. Mini-Cognitive (Mini-Cog) combines the Clock Drawing Test with the three-word recall.
When the diagnosis remains unclear, the patient may be referred for more extensive screening and neuropsychological testing, which might provide more direction and support for the patient and the caregivers.
C. Functional Assessment
1. Tests that assess functional limitations such as the Functional Activities Questionnaire (FAQ) can detect dementia. They are also useful in monitoring the progression of functional decline.
2. The severity of disease progression in dementia can be demonstrated by performance decline in activities of daily living (ADL) and instrumental activities of daily living (IADL) tasks and is closely correlated with mental-status scores.
D. Behavioral Assessment
1. Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations.
2. Evaluate for depression because it commonly coexists in individuals with dementia. The Geriatric Depression Scale (GDS) is a good screening tool.
E. Physical Assessment
1. A comprehensive physical examination with a focus on the neurological and cardiovascular system is indicated in individuals with dementia to identify the potential cause and/or the existence of a reversible form of cognitive impairment.
2. A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal, and nutritional products taken is done to determine the potential impact on cognitive status.
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 appropriate in the routine initial evaluation of patients with dementia.
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. (For CSI see Try This Issue 14 - Caregiver Strain Index (CSI)).
3. Evaluate the caregiver experience and patient–caregiver relationship.
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 pharmacologic 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 incontinence; encourage an exercise routine that expends energy and promotes fatigue at bedtime; 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 (psychotropics) 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 modestly stimulating, avoiding overstimulation that can cause agitation and increase confusion, and understimulation that can cause sensory deprivation and withdrawal. 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 aides 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.
I. Provide appropriate end-of-life care in terminal phase: provide comfort measures 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 caregivers 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 associations, respite care, specialized long-term care) and informal (e.g., churches, neighbors, extended family/friends) support systems.
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 effective 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.
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.
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’s Disease:http://www.aagponline.org/prof/position_caredmnalz.asp
C. Alzheimer’s Foundation of America (AFA): Excellence in Care:http://www.alzfdn.org
For Definition of Levels of Quantitative Evidence Click Here
From Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. © Springer Publishing Company, LLC.
Last updated - August 2012