Dementia is a commonly used term, formerly used to describe a decline in mental cognition that interferes with daily life. Dementia has been replaced in the DSM-V criteria by the term Major Neurocognitive Disorder (MND). Patients with MND experience a significant decline in cognition along with a decrease in the ability to perform everyday tasks. Symptoms are persistent and progress over time. It is important to note that MND is not a normal or expected part of aging.
Alzheimer’s disease is the most common type of MND, representing about 70% of all cases. Alzheimer’s disease is progressive, beginning with a preclinical stage that usually doesn’t present with symptoms, though changes in the brain are occurring. The patient then progresses through mild, moderate, and severe stages, which may occur gradually over a span of years. At this time, there is no cure for Alzheimer’s disease, though research is ongoing to uncover treatments to alleviate symptoms, delay onset, and identify biomarkers of the disease.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Memory
- Self-Care Deficit
- Social Isolation
- Risk For Falls
Nursing Process
As MND progresses, it can result in self-care deficits in bathing, grooming, toileting, and feeding. Alzheimer’s disease can lead to swallowing difficulties as the patient loses their ability to swallow, which can result in life-threatening aspiration pneumonia. Falls are also common due to the loss of reasoning ability and judgment. Patients may not be able to ambulate independently, yet they will attempt to get out of bed or a wheelchair unassisted. In one study, half of the patients with dementia who were admitted to the hospital for either pneumonia or a hip fracture died within six months of discharge.
Nurses may treat patients for an array of physical conditions that are complicated by these neurocognitive disorders. Understanding the importance of safety and the emotional and mental challenges these patients and their families face is imperative to providing the best care.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to dementia and Alzheimer’s disease.
Review of Health History
1. Review medical history with the patient and/or caregiver.
Pre-existing medical conditions that increase the risk for neurocognitive disorders include:
- Atherosclerosis
- Obesity
- Hypertension
- Dyslipidemia
- Diabetes
- Depression
- History of concussion or head trauma
2. Consider nonmodifiable risk factors.
The following are nonmodifiable risk factors that may contribute to Alzheimer’s disease/MND:
- Advancing age
- Family history of MND or Alzheimer’s disease
- Genetic mutations
- Down syndrome
- Female gender
3. Review the family history with the patient and/or caregiver.
The risk of dementia increases with a family history of a first-degree relative with MND.
4. Review substance abuse history with the patient and/or caregiver.
Heavy alcohol consumption and smoking alters the brain. Alcohol use disorders have been linked with an increased risk of dementia, particularly early-onset dementia. While smoking may raise the chance of blood vessel disease and dementia.
5. Review the medication list with the patient and/or caregiver.
Medications such as some analgesics, antihistamines, CNS agents, muscle relaxers, and respiratory medications may cause delirium and confusion in patients over the age of 65 as a side effect of the medication.
6. Discuss MND symptoms with the patient and/or caregiver to develop a baseline.
Patients may or may not be aware of changes in their cognition. Symptoms are progressive, so it is important to determine a timeline or consider other conditions that may cause abrupt changes in mental status.
7. Determine patient’s current functional status, including instrumental ADLs.
While discussing the current level of functioning with the patient and family, compassionately ask what the patient’s self-care routine looks like at home.
- Does anyone help with ADLs such as bathing, dressing, cooking, and eating?
- Does the patient still drive?
- Are they safe at home-including questions about the ability to get out if there is a fire, risk for wandering, etc?
- Inquire about IADLs such as making appointments and managing finances.
These responses are important to aid in diagnosing and monitoring MND.
8. Determine the patient’s health and safety risk factors while hospitalized.
Patients who are hospitalized with MND may become more confused when in an unfamiliar environment, increasing the risk of agitation, falls, and elopement.
9. Review typical sleep patterns and routines with the patient and/or caregiver.
Patients with MND often lose their sleep-wake circadian pattern. This leads to fragmented and disrupted sleep. Poor sleep can exacerbate neurologic deficits, including confusion, irritability, and alertness. It can also lead to sundowning, which may affect up to two-thirds of patients. Sundowning is a phenomenon that occurs in the evening hours and most frequently presents with paranoid delusions.
Physical Assessment
1. Assess the patient’s appearance, gait, and general affect.
Observe the patient’s general appearance, personal hygiene, dress, and posture. Observe the patient’s gait and balance. The nurse may also note the patient’s affect, responsiveness, and mood during the interaction for clues about cognition.
2. Assess the patient’s level of orientation.
Assess the patient’s mental status through the following evaluations:
- Orientation to person, place, time, and situation
- Speech clarity
- Ability to follow directions
- Attention span and concentration
- Appropriateness of responses
3. Use standardized assessments to evaluate the patient.
Neuropsychological tests are typically administered by a physician or advanced provider. The nurse may assist or review results of tests, such as:
- Mini-Mental Status Examination (MMSE)
- The Saint Louis University Mental Status (SLUMS) exam
- The Montreal Cognitive Assessment (MoCA)
4. Observe symptoms affecting cognition and physical function.
MND is a progressive disease. Alzheimer’s disease includes defined stages:
- Preclinical: changes are occurring in the brain decades before any clinical symptoms can be detected. Typically, at this stage, assessment and neurologic testing are normal.
- Mild: memory loss begins to become noticeable, including confusion and forgetfulness about once familiar places. Daily tasks may take longer, money management may become more difficult, spontaneity may diminish, and personality changes may occur with an increase in anxiety. This is the stage where an AD diagnosis most often occurs.
- Moderate: as damage to the brain continues to spread, memory loss and confusion worsen. There is often trouble with language (written, read, and spoken), logical thinking, and learning new things. Anger may result as a mask for confusion or anxiety. Changes in behavior, such as wandering may occur, and hallucinations, paranoia, and irritability are common.
- Severe: The final stage of AD occurs when areas of the brain have atrophied, and plaques and tangles are widespread throughout. Patients with severe AD are unable to recognize once familiar faces and cannot communicate in any meaningful way. These patients may exhibit physical symptoms of their advanced disease, including weight loss, difficulty swallowing, increased sleeping, and loss of bladder and bowel control. Frequently, these patients are bed bound, and death occurs as a result of secondary causes such as aspiration pneumonia.
Diagnostic Procedures
1. Obtain blood samples.
Laboratory tests may help rule out other conditions affecting cognition. These include:
- Complete blood count
- Urinalysis
- Metabolic panel
- Vitamin B12
- Folic acid
- Thyroid function tests
- Serological tests for syphilis and HIV
- Under some circumstances providers may order:
- Erythrocyte sedimentation rate
- Lumbar puncture to check cerebrospinal fluid for various protein markers
- Heavy metal screen
- Ceruloplasmin levels
- Lyme disease titer
- Serum protein electrophoresis
2. Perform diagnostic imaging.
Diagnostic imaging of the brain is often ordered for initial evaluation, early onset, atypical presentation, or rapidly progressing cognitive decline. Common imaging tests ordered for MND and Alzheimer’s disease evaluation include:
- Brain magnetic resonance imaging (MRI) evaluates vascular and ischemic disease and localized areas of the brain or global atrophy that may be present.
- Computerized tomography (CT) rules out the presence of any acute neurologic concern such as a stroke or a mass in the brain that could be causing sudden onset symptoms. It will not provide any information to aid in a dementia diagnosis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with dementia or Alzheimer’s disease.
1. Administer medications as ordered.
Treatments to enhance cognitive function include the following medications:
- N-methyl-D-aspartate (NMDA) antagonist reduces glutamine’s action:
- Namenda
- Cholinesterase inhibitors slow the progression of symptoms by preventing the breakdown of acetylcholine:
- Galantamine
- Rivastigmine
- Donepezil
- Anti-amyloid beta monoclonal antibodies are the first disease-modifying treatment for Alzheimer’s disease, which should be implemented in the mild stage of development. The two FDA-approved medications in the US are:
- donanemab (Kisunla)
- lecanemab (Leqembi)
Medications to manage secondary symptoms include:
- Antidepressants or mood stabilizers to manage irritability, depression, and rage
- Neuroleptics to manage hallucinations and delusions
- Anxiolytics to manage anxiety and agitation
2. Encourage lifestyle modifications.
Lifestyle changes to maximize cognitive performance include:
- Enhancing sleep
- Consuming an anti-inflammatory diet
- Routine physical activity
- Treating hearing or vision loss
- Reducing stress
- Avoiding heavy alcohol use
- Keeping cholesterol, blood pressure, and glucose levels within normal ranges
3. Provide a safe environment.
Patients with dementia may find it easier to concentrate and move if there is less clutter and noise. Create a safe environment, such as removing dangerous objects and maintaining a tidy space. Implement monitoring systems if the patient wanders or may attempt to get out of bed without calling for assistance.
4. Encourage mental activities to support cognition.
Mentally stimulating activities such as crossword puzzles and brain teasers help keep the mind active and may slow the progression of dementia.
5. Involve the patient’s caregivers.
Provide patients and their families with all relevant information about what to anticipate with the disease process of MND. Educate caregivers on techniques like reassuring and redirecting patients instead of correcting them repeatedly when they become disoriented, which will help prevent unnecessary irritability.
6. Provide support to the patient and their family.
Urge patients and their families to register with support organizations and societies and utilize resources for financial support, respite, and more in their area.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for Alzheimer’s disease or dementia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for Alzheimer’s disease or dementia.
Disturbed Sensory Perception
Sensory visual disturbances may occur in Alzheimer’s disease due to cortical disturbances. The accumulation of neurofibrillary tangles and neuritic plaques in the visual cortical areas that cause degeneration and atrophy of the cortical region of the brain result in the higher visual ability being compromised.
Nursing Diagnosis: Disturbed Sensory Perception
Related to:
- Alzheimer’s disease
- Sleep disorders
- Depression
- Excessive stimuli
- Medication side effects
As evidenced by:
- Changes in sensory acuity
- Personality changes
- Irritability
- Hallucinations
- Altered patterns of communication
- Confusion
Expected outcomes:
- Patient will be able to properly identify objects and sounds.
- Patient will maintain their baseline level of cognition.
Assessment:
1. Assess the patient’s level of cognition.
Complete a full history and neurologic evaluation, including orientation, mental acuity, and behavioral changes.
2. Assess the patient’s senses for any abnormalities.
Alterations in the patient’s auditory or visual senses are common in older patients with dementia and can significantly affect their sensory perception and increase the risk for complications like falls and injuries.
3. Assess other factors that may contribute to the alteration.
Neurological disorders, medications, electrolyte imbalances, excessive environmental stimuli, and underlying health conditions may significantly affect the patient’s sensory perception.
Interventions:
1. Administer treatment for causes that may be exacerbating disturbed sensory perception.
Ensure management of high fevers, polypharmacy, or electrolyte imbalances (especially hyponatremia and hypocalcemia) that may be contributing to sensory disruptions.
2. Encourage the use of visual or auditory aids.
Patients with dementia are often of older age and have decreased visual and/or auditory acuity. Corrective glasses, magnifying glasses, brighter lighting, and hearing aids can help stimulate and improve the patient’s sensory perception.
3. Ensure fall precautions are in place.
Fall precautions include keeping the bedside rails up, using the bed alarm, ensuring the call light is within reach, and keeping the bed in the lowest position. Maintaining fall precautions can help reduce the risk of falls or injuries in patients with dementia suffering from kinesthetic alterations and impairment.
4. Instruct the patient to avoid extreme temperatures.
Tactile issues are also common in patients with dementia suffering from disturbed sensory perception. Implement strategies to avoid exposure to extreme temperatures to reduce the risk of burns and injuries.
5. Offer reassurance and distraction.
Hallucinations and delusions can be frightening. Refrain from trying to convince the patient they are wrong, as this can cause further distress. Instead, reassure them and offer distraction techniques.
6. Balance stimulation with rest.
Patients with dementia benefit from social stimulation and should not be isolated. Attempt to balance activities with rest to prevent sensory overload.
Impaired Memory
Patients diagnosed with dementia experience a significant decline in at least one domain of cognition that is persistent and progressive.
Nursing Diagnosis: Impaired Memory
Related to:
- Brain injury
- Neurological impairment
- Mild cognitive impairment
As evidenced by:
- Persistent forgetfulness
- Persistent inability to recall events
- Persistent inability to recall familiar names or information
- Persistent inability to learn new information
- Persistent inability to learn a new skill
Expected outcomes:
- Patient will demonstrate techniques to help improve memory impairment.
- Patient will display improved memory through daily activities and interactions.
Assessment:
1. Assess the overall cognitive function of the patient.
Utilize a brief screening tool such as the Montreal Cognitive Assessment (MoCA). Assess for reversible conditions that can acutely worsen cognitive function, such as electrolyte disturbances, medication effects, hypoxia, hypothyroidism, drug and alcohol abuse, and infections.
2. Review the medication list.
Review the list of medications prescribed for the patient for accuracy and appropriateness. Monitor for side effects following administration of the medications. In patients over 65 years old, some medications may cause more adverse cognitive effects.
3. Assess for sleep quality.
Disturbed sleep patterns or ineffective sleep quality are a common problem in patients with dementia. If sleep quality or quantity is insufficient, or there are symptoms of sleep disorders such as obstructive sleep apnea (OSA), initiate sleep modifications.
4. Assess for safety concerns.
Patients with dementia may be at a higher risk for skin breakdown, aspiration pneumonia, falls, and elopement. Perform facility specific screening tools for skin integrity, fall risk, and dysphagia to support the patient.
Interventions:
1. Orient the patient to the environment as needed.
Reality orientation will help promote awareness of self and the environment, decrease anxiety, and promote a trusting relationship.
2. Assist the patient in utilizing cognitive techniques for memory.
Cues and external cognitive strategies like calendars or alarms can help patients with dementia remember important appointments and events.
3. Assist the patient in setting up a medication box.
A medication box or pill organizer will help remind the patient to take certain medications at their prescribed times. The medication box will also help caregivers to monitor whether the patient is adherent to their medications.
4. Encourage good sleep hygiene techniques.
Daily activities like exercise, exposure to light, avoiding large meals before bed, arising at the same time each day, and avoiding long periods of daytime sleep will help with sleep readiness, which can promote cognition.
5. Educate on memory-enhancing techniques and cognitive rehabilitation programs.
Encourage the use of techniques such as concentrating and attending, repeating information that is heard, making mental associations, and placing items strategically in places so they will not be forgotten. Multicomponent cognitive rehabilitation programs focus on correcting memory deficits to improve attention, judgment, and processing.
Self-Care Deficit
Nursing Diagnosis: Self-Care Deficit
Related to:
- Weakness
- Depression
- Cognitive decline
- Impaired Judgment
- Poor decision-making
- Inability to communicate needs
- Incontinence
- Declining motor skills
As evidenced by:
- Transferring or ambulation difficulties
- Inability to safely prepare food
- Inability to handle utensils
- Swallowing difficulties
- Lack of judgment in clothing choices (shorts in winter, scarf in summer)
- Difficulty in dressing self
- Re-wearing dirty clothing
- Inability to safely regulate water temperature for bathing
- Inability to recognize urge or remove clothing for elimination
- Needing reminders or coaching to complete tasks
- Inability to maintain hygiene (unbrushed hair or teeth, unshaven face, body odor)
Expected Outcomes:
- Patient will maintain independence in dressing, bathing, and toileting for as long as possible
- Patient will prepare meals and feed themselves within their abilities to maintain safety
- Patient will alert their caregiver to needs (requesting a drink, needing to use bathroom)
Assessment:
1. Assess their level of abilities.
Observe the patient to assess their physical and mental capabilities. Dementia patients may try to hide their loss of self-care or may be unaware of the extent of their loss of decision-making. Assess for safety concerns, errors in judgment, or areas to enhance and support their self-care activities.
2. Determine caregiver support.
Caring for those with dementia can be time-consuming and exhausting for family members. Assess family and caregivers to ensure they understand how to support their loved one at home. Suggest paid caregiver support if needed or refer to community resources that offer volunteers or equipment needed in the home.
Interventions:
1. Maintain a schedule and routine.
The family or caregiver should encourage a routine each day that includes dressing, bathing, meal times, and elimination practices. This prevents confusion and helps the patient maintain organization and independence.
2. Offer simple choices.
Patients with dementia can often become overwhelmed when making decisions and cannot translate too much information at once. Regardless, patients should still be respected and given options in their daily lives. When offering decisions, keep it simple: oatmeal or toast for breakfast, black or gray shoes, bathing before or after dinner.
3. Consider resources to improve self-care.
Implement equipment to improve safety and assist the patient with accomplishing tasks. Handheld showerheads, grab bars, and benches can make bathing easier and safer. A stairlift, toilet risers, and riser-recliner chairs can help the patient with mobility. Eating equipment such as non-spill cups or easy-grip cutlery can improve eating habits.
4. Make dressing easier.
If a patient struggles with choosing appropriate attire or can’t decide between clothing options, but still maintains the motor function to dress themselves, a caregiver can lay out clothing. Increase the ease of dressing by only using clothing that doesn’t have buttons or zippers. Swap out shoes with laces for Velcro or slip-on shoes.
5. Use signage around the house.
Labels, post-it notes, whiteboards, clocks, and timers can be used anywhere they are needed. These serve as reminders and can help with memory recall. Leaving a note on the bathroom mirror such as “brush your teeth” or setting an alarm when it’s time to take medication are simple additions to improve self-care.
Social Isolation
Nursing Diagnosis: Social Isolation
Related to:
- Declining cognition
- Difficulty with speech
- Personality changes (anger, inappropriately vulgar or sexual speech/behavior)
- Confusion
- Physical deconditioning
- Depression
As evidenced by:
- Forgetting names or dates
- Repeating questions or information
- No longer able to drive
- Inability to recognize friends or family
- Needing assistance with basic self-care
- Incontinence
- Disturbed sleep patterns
- Nonverbal
- Agitation or combativeness
- Paranoia
Expected Outcomes:
- Patient will maintain meaningful relationships with friends and family for as long as possible
- Patient will seek social support through support groups, organizations, and the community to ease the burden of their disease
- Patient will maintain an active and enriched lifestyle, partaking in activities and hobbies
Assessment:
1. Assess for a support system.
Assess for family members, friends, or other support systems such as church members or community groups that assist the patient with everyday activities and social stimulation.
2. Determine physical and mental limitations.
Assess for symptoms related to the disease that is causing isolation. Physical limitations may include an inability to ambulate or care for themselves, while cognitive limitations such as an inability to communicate or socially unacceptable behavior will prevent regular socialization.
3. Assess for mental illness barriers.
Patients may become isolated due to embarrassment in losing their memory and forgetting simple details as well as losing their independence in activities such as driving or getting dressed. They may feel hopeless, anxious, and even become depressed, further isolating them.
Interventions:
1. Provide games and activities to their cognitive level.
Depending on the stage of their disease, provide puzzles, books, music, and exercise programs to keep their mind and body stimulated. Encourage family members to assist the patient with activities and hobbies they enjoy such as gardening or cooking, even if they aren’t able to complete tasks as they used to.
2. Refer to adult daycare centers or facilities.
Patients and families can benefit from adult daycare centers or programs for those with conditions such as Alzheimer’s disease or Parkinson’s disease that provide socialization.
3. Help them remember who they are.
Patients with dementia may become isolated from a sense of hopelessness due to a loss of their independence. Play some of their favorite music, look through family photos, or simply ask them questions about their childhood to provoke their memory and remind them of their accomplishments and purpose.
4. Get outside.
Socialization doesn’t have to be costly or difficult. Simply being in the presence of others sitting at a park provides plenty of stimulation. Being in nature, breathing in fresh air, and feeling the sun has amazing mood-boosting benefits.
Risk For Falls
Nursing Diagnosis: Risk for Falls
Related to:
- Impulsiveness
- Advanced age
- Poor mobility
- Loss of perception
- Use of assistive devices
- Incontinence
- Vision loss
- Poor balance
- Decreased coordination
- Misinterpretation of environment
- Gait abnormalities
- Confusion
- Delirium
- Medications (sedatives, antidepressants, antipsychotics)
- Depression
- Caregiver strain
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
Expected Outcomes:
- Patient will remain free from falls
- Patient will utilize assistive devices correctly to prevent falls
- Patient will call for help before ambulating or transferring
Assessment:
1. Perform a fall risk assessment.
Several fall risk scales can be utilized as well as other assessments to determine a risk for falls. The Morse Fall Scale is a common fall risk scale used on all hospitalized adults though it may not account for all of the risk factors in those with dementia. Research shows that patients with a high MMSE (Mini Mental Status Exam) score, which is used to test cognitive function, show a correlation between cognitive decline and falls.
2. Assess muscle strength and coordination.
Assess gait, stability, balance, gross and fine motor skill coordination, and the use of any assistive devices. Adults with dementia may overestimate their abilities or forget their limitations.
3. Assess judgment and perception.
Patients with dementia may appear lucid but have periods of forgetfulness or confusion. This occurs more often at night and is known as sundowning. This increases the risk of wandering. The nurse should reassess orientation regularly in dementia patients as the perception of their environment, ability to reason, and behaviors can shift.
Interventions:
1. Keep items within reach.
Water cups, eyeglasses, remote control, phone, and any frequently used items should be kept within close reach to prevent the patient from needing to move from the bed or chair to reach something.
2. Use fall alert devices.
In the hospital, bed and chair alarms should be used when a patient is identified as being a fall risk. In the home, there are also mattress and chair pads that can be used. The patient should be given a fall alert device such as a necklace to press in the event of an emergency.
3. Unclutter the environment.
For ambulatory patients, keep hallways and walking areas clear. Remove or rearrange extra furniture, remove rugs, and keep the floor free from cords. If the patient uses an assistive device this further increases the risk for a fall.
4. Consider visual acuity.
Vision issues paired with impaired cognition can lead to a misinterpretation of the environment. Poor depth perception, shadows, and glares can contribute to falls. Use night lights in hallways and bathrooms, open curtains and blinds during the day, and use lamps at night. Providing contrast is also important to help with confusion. Choose grab bars or handrails that are darker than the wall, if floors are dark, opt for light-colored furniture, and limit the use of patterns.
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