COA

• Dementia


  irreversible state that progresses over years and causes memory impairment and loss of other intellectual abilities severe enough to interfere with daily life
• Delirium


  Acute physiological disturbance
• Depression


  an array of effective, cognitive, and somatic or physiological symptoms
• Mini-Mental State Examination (MMSE)


  <24 suggests potential tests orientation, immediate and delayed recall, working memory, language, and visuospatial ability

  Adjustments are made according to education level

  Score of 30 no impairment
• Montreal Cognitive Screening (MoCA) Screening

  Designed to detect mild cognitive impairment

  30 questions; 10 minutes to complete

  >26 considered normal

  Reliable as screen test for Alzheimer's disease

  Measures executive function
• Cognitive Performance Scale (CPS) by interrail


  CPS) & (CPS2)

  Tool Created by inter-RAI

  Scores range from 0 (no memory) to 6 (severe memory impairment)

  Highly correlated with MMSE

  CPS2- more up to date

  A reliable tool for assessing cognitive impairment in acute care
• Confusion Assessment Method (CAM)

  Used to identify delirium according to the DSM-IV diagnostic criteria with a 90% sensitivity

  A positive or negative result depends on four criteria:

  Acute onset and fluctuating course- Determined by collateral history or repeated clinician assessment

  Inattention- Counting from 20-1 is a simple test for this

  Disorganised thinking

  Altered levels of consciousness

  Considered positive for the presence of delirium if both features 1 and 2 are present, with at least one of features 3 or 4
• Dementia -


  Is an umbrella term

  An irreversible state that progresses over years

  Clinical features:

  Causes memory impairment and loss of other intellectual abilities severe enough interfere with daily life

  Aphasia; Apraxia; Agnosia

  Disturbances in Executive Functioning (planning, organizing, sequencing, abstracting)
• Cerebrovascular disease


  Stroke

  All actual or potential cerebrovascular events should be treated as emergencies

  Management - preventative - aim to prevent recurrences and reduce risk factors

  Reperfusion therapy for embolic strokes only (rt-PA)

  Anticoagulants or antiplatelets to prevent recurrent embolic strokes and TIAs

  CT must confirm no hemorrhage

  Time dependent

  The initial response to a hemorrhagic stroke is to find the source & a means to stop the bleeding

  Signs and symptoms: severe headache, depressed level of consciousness, alterations in speech, movement, coordination

  Treatment - treat as an emergency, TIA's are signs that a stroke may occur, CT scans, blood work
• Parkinson's disease


  Slowly progressing disease that results from the destruction of the cells in the brain. No longer able to produce dopamine

  Cause is unknown

  Signs and symptoms: slowness of movement (bradykinesia), jerky limbs, postural instability, tremors

  Medications/treatments: increase dopamine/dopamine replacement, support, therapy, physio
• Progressively Lowered Stress Threshold model

  One of the first models used to plan and care for a patient with dementia. The structure reduced stressors and provided the person with a safe and predictable environment
• Need-driven dementia-compromised behaviour model

  proposes that behavior of a person with dementia indicates need that can be addressed appropriately if the persons history and habits, physiological status and physical and social environment are carefully evaluated. Having meaning and expressing needs.
• Recognition of retained abilities model

  Careful assessment of the persons abilities allows the nurse to assist with care in ways that compensate for lost abilities and enhance remaining abilities. Abilities are important. Increased engagement in care and increased independence in ADL's
• Relating well model


  A therapeutic relationship achieved when a care provider is reliable, empathetic, and consistent in interactions with the person with dementia. 1) stay with the resident during the episode. 2) altering the pace of care by reorganizing the persons rhythm and adapting to it. 3) focusing beyond the task
• Person-Centred Care in dementia care

  Allow the patient to make choices, allow them to be part of their care - if they can brush their hair and teeth allow them

  If they like certain activities, make sure you take time to put on a show they like, a radio station they love, take them gardening etc.
• nursing care plan for a person experiencing dementia


  Create meaningful activities

  Maximize remaining abilities

  Monitor general health:

  Impact of dementia of other conditions and relationships

  Mental Health and pain management

  Create opportunities for social engagement:

  Choice, self-expression, spirituality, and creativity

  Support Advance Care Planning

  Educate caregivers

  Resources, emotional support, respite

  
  

  Responsive Behaviours - describes reactions that result from unmet needs or environmental stress

  What can precipitate responsive behaviours?

  • Communication deficits

  • Pain or discomfort

  • Acute medical problems

  • Sleep disturbances

  • Perceptual deficits

  • Crowded conditions

  • Need for social contact
• Predisposing

  (Factors present at time of admission) Factors for Delirium

  •Demographic characteristics

  •age 65 years or older,

  •male sex

  •Cognitive status

  •Dementia, cognitive impairment, history of delirium, depression

  •Functional status

  •Dependence, immobility, low level of activity, history of falls

  •Sensory impairment

  •visual, hearing

  •Decreased oral intake

  •dehydration, malnutrition

  •Medications

  •Multiple psychoactive medications, numerous medications, alcohol abuse

  •Co-existing medical conditions

  •Severe illness, multiple comorbidities, chronic renal or hepatic disease, history of stroke, neurological disease etc.
• Precipitating

  (Sudden effect or cause to trigger?) Factors for delirium

  •Medications

  •Sedative hypnotics, narcotics, anticholinergic medications, multiple medications, alcohol or medication withdrawal

  •Primary neurological diseases

  • Stroke, intracranial bleeding, meningitis, or encephalitis

  •Intercurrent illnesses such as:

  • Infections, severe acute illness, hypoxia, dehydration, poor nutritional status

  •Surgery

  •Orthopedic, cardiac, prolonged cardiopulmonary bypass, noncardiac

  •Environmental

  •Admission to ICU, physical restraints, bladder catheter, multiple procedures

  •Pain

  •Emotional stress

  •Prolonged sleep deprivation
• Alzheimer's disease (AD)


  Most common type of dementia, accounting for 60-80% of cases.

  Hallmark abnormalities are deposits of the protein fragment beta-amyloid (plaques) and twisted strands of the protein tau (tangles).

  Difficulty remembering names and recent events; difficulty expressing oneself with words; spatial cognition problems; impaired reasoning and judgement; apathy; and depression are often early symptoms. Language disturbances may also be a presenting symptom. Later symptoms include impaired judgement, disorientation, behaviour changes, and difficulty speaking, swallowing, and walking.
• Vascular dementia (also known as multi-infarct or poststroke dementia or vascular cognitive impairment)


  Second most common type of dementia.

  Impairment is caused by decreased blood flow to parts of the brain, due to a series of small strokes that block arteries.

  Symptoms often overlap with those of AD, although memory may not be as seriously affected.
• Mixed dementia


  Characterized by the hallmark abnormalities of AD and another type of dementia (most commonly vascular dementia, but also other types, such as dementia with Lewy bodies).

  More common than previously thought. Neurodegenerative changes occur along with vascular changes.
• Parkinson's disease dementia


  Later onset of dementia (at least 1 year after onset of parkinsonian features).

  Hallmark abnormality is Lewy bodies (abnormal deposits of the protein alpha-synuclein) that forms inside the nerve cells of the brain.
• Dementia with Lewy bodies


  Pattern of decline is similar to that of AD, including problems with memory and judgement as well as behaviour changes.

  Alertness and severity of cognitive symptoms may fluctuate daily.

  Visual hallucinations, muscle rigidity, and tremors are common.

  Exhibits a sensitivity to neuroleptic drugs, so these medications should be avoided.
• Creutzfeldt-Jakob disease and variant Creutzfeldt-Jakob disease (vCJD) (transmissible bovine spongiform encephalopathy [mad cow disease])


  A rapidly fatal and rare form of dementia, characterized by tiny holes that give the brain a "spongy" appearance under microscope.

  May be hereditary, occur sporadically, or be transmitted from infected individuals.

  Failing memory, behavioural changes, lack of coordination, visual disturbances.

  vCJD occurs in younger patients; may be caused by contaminated cattle feed.
• Frontotemporal dementia


  nvolves damage to brain cells, especially in the front and side regions of the brain.

  Symptoms include change in personality and behaviour and difficulty with language.

  Pick's disease, characterized by Pick's bodies in the brain, is one form of frontotemporal dementia.
• Normal-pressure hydrocephalus


  Caused by buildup of fluid in the brain without corresponding increase in cerebrospinal fluid pressure.

  Symptoms include difficulty walking (ataxic gait), memory loss, and incontinence.

  Can sometimes be corrected with surgical installation of a shunt to drain excess fluid.
• Gradual adaptation to retirement


  lessen how may days a week they work, not ready to let go and say goodbye to their career.
• Non traditional families


  Are more likely to live alone in older age. Negative experiences due to prejudice and discrimination results in realistic fear of disclosing sexuality creating barriers to accessing care
• Older People and their adult children


  These relationships are both the most important and potentially the most conflicted. Most older adults and their children have relationships that are reciprocal in nature and characterized by affection and mutual support. Relationships may become strained because younger adults are more concerned with their own spouses, partners, and children
• Widowhood


  usually the men pass first, woman have longer life span. One of the most difficult transitions to go through. Men are more likely to remarry. Get extremely lonely. Suicide risks in widowed men are very high
• Successful Retirement planning depends on

  · Socialization needs

  · Energy levels

  · Health

  · Adequate income

  · Variety of interests

  · Amount of self-esteem derived from work

  · Presence of intimate relationships

  · Social support

  · General adaptability
• Four dimensions of grief reactions


  Affective, cognitive, behavioural, physiological-somatic, extensional dimension
• Affective


  depression, despair, loneliness
• Cognitive


  denial, helplessness, difficulty concentrating, preoccupation with thoughts of the deceased
• Behavioural


  agitation, weeping, social withdrawal, fatigue
• Physiological-Somatic


  loss of appetite, sleep disturbances
• Existential Dimension


  searching for meaning in the death, questioning spiritual beliefs
• Patterns of Adjustment to Widowhood

  Stage 1 - disbelief, anger, indecision, detachment, inability to communicate in a logical, visions, hallucinations

  Stage 2- depression, apathy, movement, and cognition are slowed, insomnia, unpredictable waves of grieve, sighing, anorexia. Watch for suicide! Protect against suicide

  Stage 3 - Periods of depression, feeling of personal control starts to begin,

  Stage 4 - Begins new adventures, tests suitability of new roles, special occasions - anniversary, birthdays etc may be extremely difficult

  Stage 5 - Person feels fully integrated into new role, satisfied with their role, grief resolved in a healthy manner
• myths regarding sexuality and aging

  Hysterectomy create physically disability to function sexually

  Sex has no role in the lives of our older adults

  Sexual expression in old age is taboo

  Too old and fragile to have sex

  ALL MYTHS - sex is good for the heart

  Support everyone with their sexuality, do not judge them, do not bring your ethics into any situation, it is their life
• intimacy and sexuality in long-term care homes


  Long term care homes create a barrier and have a lack of privacy! Hard to do sexual activity, expressions, hugging, kissing, holding hands, contact. NO PRIVACY which impacts intimacy and sexuality

  STI's are increasing

  If you are not comfortable with seniors having sex, leave it at the door. It is their choice, let them live their life.