4. Delirium, dementia, and amnestic and other cognitive disorders

Any physiologic condition or pathophysiologic process that is capable of destroying or altering brain tissue impairs cerebral functioning. Regardless of the physical cause, the symptoms are typically cognitive impairment, behavioral dysfunctions, and personality changes. The most common symptomatology noted from the DSM-IV category is delirium, dementia, and amnestic disorders. (For further information, see Major Cognitive Disorders, page 58.)

Delirium

DSM-IV CATEGORIES

293.0 Delirium due to ... (indicate the general medical condition)

__._ Substance intoxication delirium (refer to substance-related disorders for substance-specific codes)

__._ Substance withdrawal delirium (refer to substance-related disorders for substance-specific codes)

__._ Delirium due to multiple etiologies (code each of the specific etiologies)

780.09 Delirium NOS

With this disorder, a person exhibits a disturbance in consciousness and a change in cognition unexplainable by a prior or currently developing dementia. The disturbance occurs over a short period and changes its presentation during the day. Typically, the delirium resolves in hours or days unless a concurrent dementia is present. The health examination and laboratory work indicate that the delirium is a result of a physiologic medical condition. substance intoxication or withdrawal, medication use, toxic exposure, or a combination of these factors. The sooner the underlying problem is identified, the faster the symptoms can be corrected and the delirium resolved. Delirium can affect all cllients, but it's most prevalent in people over age 65 who are hosci-talized for a general medical or surgical problem.

MAJOR COGNITIVE DISORDERS
TYPE OF DISORDER	COMMON SYMPTOMS
Delirium disorder	Lack of response to environmental stimuli Disorientation Disorganized thinking Rambling or incoherent speech Illusions or hallucinations Insomnia or daytime sleepiness Impaired psychomotor skills
Dementia disorder	Short- and long-term memory impairment Impaired abstract thinking Impaired judgment Impaired social and occupational functioning Changes in personality
Amnestic disorder	Memory impairment (due to a medical problem or persistent use of a drug) Impairment in ability to learn new information Inability to recall past situations Memory disturbance not occurring during a delirium or a dementia Impaired social and occupational functioning compared with prior level of functioning Confabulation (gaps in memory filled in with fabrications) Apathy Shallow affect

Symptomatically, the client presents with impairment in attention demonstrated by being easily distracted and unable to rc-cus or shift attention from one topic to the another. The probler". may be so serious that the person can't be engaged in a conversation. In addition, there is a major change in cognition manifested by disorientation, especially to time and place; memory impairment particularly recent memory; and language disturbance, primarily the inability to write and name objects. Speech may be rambling and incoherent as the client moves quickly from one topic to another. Sensory disturbances, such as misinterpretations, illusions, or even hallucinations, can occur.

Delirium is often accompanied by disturbed psychomotor behavior, such as sudden movements, hyperactivity, restlessness, and picking at clothing. Psychomotor activity may vary from the hyperactive extreme to a slowed, lethargic state during the course of a day. The client also shows unpredictable, changing emotional states such as apathy, anxiety, depression, irritability, anger, fear, and euphoria. A person who displays these symptoms is at risk for self-injury and may also hurt others because of overwhelming fear or an altered mental state.

The neurobiological mechanisms underlying the development of delirium aren't well understood. Common pathological causes of delirium include drug intoxication and withdrawal, poisoning, systemic and intracranial infections, metabolic disorders, neurologic disorders, brain lesions, and severe physical injury. Psycho-social stressors, such as abrupt life changes, as well as sensory overload or deprivation and sleep deprivation can also provoke delirium. Some commonly prescribed medications (antiarrhythmics, antihistamines, antihypertensives, psychotro-pics, anticholinergics, and analgesics) can also induce delirium.

SUBSTANCE-INDUCED DELIRIUM

One of the main types of delirium is substance-induced delirium When the delirium occurs during substance intoxication, it's called substance intoxication delirium: if it occurs during substance withdrawal, it's diagnosed as substance withdrawal delirium. The delirium manifested by substance intoxication occurs after large amounts of specific drugs, such as cocaine, alcohol, and hallucinogens have been taken. The episode of delirium resolves as the intoxication ends. With substance withdrawal delirium, the delirium occurs after a reduction in or cessation of substance use and tissue and fluid levels of the substance decrease. The duration of the delirium depends on the half-life of the substance involved. Usually, substance withdrawal delirium lasts for several hours, but it may continue for up to 4 weeks.

COMMUNICATION STRATEGIES

• Approach the client from the front rather than from behind to prevent a startle response.
• Introduce yourself to the client at each encounter.
• Talk in a quiet, calm, and unhurried manner.
• Don't confront the client about delusional beliefs and statements.
• Use touch judiciously, and ask permission before touching the client.
• Explain procedure or routine before carrying it out.
• Break down each request into simple, achievable steps.
• Requests need to be specific and focused, rather than abstract.
• Use verbal communication to orient the client to reduce environmental distress.
• Communicate nonverbally when the client has lost the use of language.

NURSING DIAGNOSIS: RISK FOR INJURY

Probable Causes	Defining Characteristics
Genetic predisposition for substance abuse disorder	Agitated behavior
Metabolic or neurologic changes associated with substance abuse	Dysfunctional behaviors
Delusions or hallucinations	Balance difficulties or falling
Intoxication or withdrawal from use of psychoactive substance	Failure to observe usual safety rules, such as stopping at a street corner before crossing and testing water temperature before bathing
Inability to assess reality and potential dangers in the environment	Inappropriate handling of items such as glass and machinery

Long-Term Goal
The client will maintain a safe and optimal level of functioning.

Short-Term Goal #1: The client will have decreased periods of confusion and will maintain contact with reality.

Interventions and Rationales

• Orient the client to the surroundings as necessary. Orientation to surroundings helps the client avoid the confusion and frustration associated with loss of contact with reality.
• Monitor the environment, and prevent overstimulation from and misinterpretation of stimuli. This action decreases confusion. anxiety, and the sense of being overwhelmed.
• List and assess all the risk factors that decrease the client's coping ability, including unsafe environment, emotional lability, occupational hazards, and family dysfunction. Comprehensive assessment data enable the staff to construct a plan of care that focuses on the client's unique safety needs.
• Obtain a complete drug use history from the client or significant others, along with laboratory test results. Knowledge of psychoactive substances used allows the staff to anticipate potential needs as well as problems.

Short-Term Goal #2: The client will interact appropriately with staff on a daily basis.

Interventions and Rationales

• Designate a contact person to observe the client frequently and initiate one-on-one interactions or guidance. Consistent contact with the same person helps build the client's trust.
• Begin to give the client structured and limited opportunities for making simple decisions. This action promotes self-esteem while keeping anxiety at a manageable level.
• Encourage the client to talk about feelings of sadness, loneliness, and loss. Discussion of emotions allows the client to begin to grieve rather than act out troublesome feelings.
• Evaluate the feelings and behaviors that put the client at risk for injury. This provides insight into the client's ability to make judgments and control impulses.

NURSING DIAGNOSIS: SENSORY/PERCEPTUAL ALTERATIONS, INCLUDING VISUAL AND AUDITORY HALLUCINATIONS

Probable Causes	Defining Characteristics
Alteration in neurotransmitters serotonin, and dopamine levels associated with substance abuse Seizure disorder Cerebral hypoxia Intoxication from use of a psychoactive substance Severe anxiety	Disorientation Cognitive impairment Irritability Aggressive behavior Inability to problem solve or make decisions

Long-Term Goal
The client will learn to function normally by managing the stress associated with delusions, abnormal sensations, and hallucinations.

Short-Term Goal #1: The client will develop methods to manage the stress associated with delusional thinking and misperceptions.

Interventions and Rationales

• Determine the degree of the client's cognitive impairment by performing a mental status assessment, focusing on changes in orientation, memory, intellect, and judgment. Assessment data provide a baseline for evaluating future behaviors.
• Communicate clearly, frequently, and about one topic or item at a time. Excessive input can provoke stress reactions: the nurse must not confuse the client with excessive information.
• Incorporate nonverbal communication into the interaction or use it more frequently if that is the predominant way the client communicates. Nonverbal communication may be used if the client has significant cognitive impairment or is fearful about communicating with others.
• Work with the client to identify stressors and develop ways to cope more effectively with those stressors that are unavoidable. Identifying stressors, providing ways to cope, and including ways to relax allow the client some relief from anxious and fearful situations.
• Introduce the client to methods of relaxation, such as breathing techniques, progressive muscle relaxation, and visualization. The use of relaxation techniques enables the client to decrease anxiety.

Short-Term Goal #2: The client will reduce bizarre or inappropriate behavior and relate appropriately to the everyday environment.

Interventions and Rationales

• Create a structured, safe, and supportive environment. A structured environment enhances the client's sense of safety, promotes consistency in the client's behavior, and decreases stress and anxiety.
• Help the client change inappropriate behavior by directing the client's energy to different, more appropriate behavior. Taking a constructive, matter-of-fact approach to problems offers the client options for changing behavior without making the client feel negative about himself
• Allow only gradual, controlled changes in the client's environment. Gradual introduction to changes in the environment allows the client time to correctly process them.
• Teach, repeat, role model, and reinforce strategies to deal with anxiety, such as identifying defense mechanisms (rationalization and projection), controlling obsessional thinking, avoiding all-or-none thinking, and engaging in assertive rather than passive behaviors. Clients with cognitive impairment are anxious; they have difficulty concentrating and comprehending information. Therefore, reinforcement and role modeling are necessary strategies for assisting the client to learn self-control over inappropriate behaviors.

THERAPIES

A client with delirium requires prompt medical intervention. Once the client is stabilized, some limited individual therapy and group therapy may be useful.

Medical/Biological Interventions

• Perform a physical examination, toxicological tests, and diagnostic studies to identify possible medical conditions and physiologic damage caused by the substance abuse.
• Medically treat all physiologic problems.
• Treat for depression, anxiety, and insomnia.
• Promote physical health and support optimal level of functioning.
• Administer medications to assist with detoxification from substances.

Individual Therapy

• Promote orientation to the environment by discussing what is happening in the here and now.
• Validate reality by interpreting sounds or things in the environment.
• Work to decrease the client's aggressive behaviors and defenses by encouraging the client to talk about anxiety and fears and by helping the client to feel understood.
• As delirium subsides, assist the client to talk about the use of psychoactive substances.
• Begin, if possible, to discuss and role model positive coping behaviors.
• Talk to the client about referral and counseling for substance use and abuse issues.

Group Therapy

Only when delirium has subsided can a client be in a group, initiate contact, and acknowledge other people.

• Promote orientation to the environment.
• Discuss the here and now for brief periods.
• Provide socialization.
• Encourage reminiscing therapy, which focuses on sharing past memories.
• Assist participants to increase self-esteem.
• Encourage clients to talk to one another.

MEDICATIONS

Medications are used to manage the underlying causes of the client's delirium, current health condition, and symptoms associated with an agitated state.

MEDICATIONS USED FOR DETOXIFICATION
TYPE OF DRUG ABUSED	MEDICATION TREATMENT
Alcohol	Anxiolytics Anticonvulsants Multivltamin supplements
Depressants	Anticonvulsants Anxiolytics
Stimulants	Anxiolytics Antihypertensives
Narcotics	Narcotic antagonists Methadone
Hallucinogens and cannabinols	Anxiolytics (infrequently)

• Administer appropriate medications to assist with detoxification. Anxiolytics are used to treat symptoms of alcohol, opioid, and amphetamine withdrawal.
• Tricyclic antidepressants may be used to treat depression. " Antipsychotics in low doses may be used to treat anxiety or agitation. Haloperidol (Haldol) is commonly given in small doses when the client is notably paranoid or angry or is threatening people.
• Vasodilators are often used to increase cerebral circulation and enhance cognition.
• Medications that stimulate neurotransmitter action are being researched. (For further information, see Medications Used for Detoxification and Appendix D.)

FAMILY CARE

• Provide the family with information and emotional support.
• Help the family deal with negative feelings about the client's substance use.
• Teach the family how to manage or advocate for the client's self-care needs.
• Identify community resources, skilled nursing and homemaker services, and support groups for caretakers and other family members.
• Evaluate the home environment, and assist the family to make necessary changes for safety.
• Encourage family members to verbalize their feelings, concerns, and frustrations about the situation they face. Communication between family members and the client is difficult because of the client's cognitive impairment. Anxiety is high due to medical problems, fears, and stress related to disruption in lifestyle routine.
• Educate family members about the principles of mental health.
• Help family members to express their grief over the lost potential of the client.

Dementia

DSM-IV CATEGORIES

290.xx Dementia of the Alzheimer's type, with early onset

290.10 Dementia of the Alzheimer's type, uncomplicated

290.11 Dementia of the Alzheimer's type, with delirium

290.12 Dementia of the Alzheimer's type, with delusions

290.13 Dementia of the Alzheimer's type, with depressed mood

290.xx Dementia of the Alzheimer's type, with late onset

290.0 Dementia of the Alzheimer's type, uncomplicated

290.3 Dementia of the Alzheimer's type, with delirium

290.20 Dementia of the Alzheimer's type, with delusions

290.21 Dementia of the Alzheimer's type, with depressed mood

290.xx Vascular dementia

290.40 Vascular dementia, uncomplicated

290.41 Vascular dementia, with delirium

290.42 Vascular dementia, with delusions

290.43 Vascular dementia, with depressed mood

294.9 Dementia due to H IV disease

294.1 Dementia due to head trauma

294.1 Dementia due to Parkinson's disease

294.1 Dementia due to Huntington's disease

290.10 Dementia due to Pick's disease

290.10 Dementia due to Creutzfeldt-Jakob disease

294.1 Dementia due to ... [indicate the general medical condition not listed above]

__._ Substance-induced persisting dementia (refer to substance-related disorders for substance-specific codes)

__._ Dementia due to multiple etiologies

294.8 Dementia NOS

A dementia disorder is manifested by multiple cognitive deficits. such as impaired memory, aphasia (loss of speech, writing ability or language comprehension due to disease of the brain such as Alzheimer's Disease [AD] or cerebrovascular disease), apraxia (loss of ability to carry out purposeful movements in the absence of motor or sensory impairment), agnosia (loss of ability to recognize objects despite intact sensory functioning), and a disturbance in occupational or social functioning. These defects can occur as a direct result of a medical problem, the effects of a substance, or a combination of causes, such as AD and cerebrovascular disease. Memory impairment may be first noticed as losing or misplacing persona] items, such as keys and jewelry: forgetting things, such as food that is cooking; and becoming lost in ones own neighborhood. As the memory impairment worsens, the person may forget his name, his birthday, and the names of family members. The ability to comprehend speech or written language becomes compromised. In advanced stages of dementia, the person may become mute or develop a speech pattern characterized by echolalia (repetition of another person's words or phrases) or palilalia (repeating words or sounds over and over). Difficulty performing motor activities, such as combing hair, brushing teeth, and writing name, becomes pronounced.

Disturbances in executive functioning are seen in the loss or the ability to think abstractly. The person with dementia has difficulty performing tasks and begins to avoid situations in which new information must be processed. There is also an inability to plan, sequence, and discontinue complex behaviors. People with dementia become spatially disoriented, demonstrate poor judgment, and have limited or no insight. They tend to overestimate their own abilities and the activities that they can participate in and accomplish. Often there is a disturbance of gait that precipitates falls. Some people manifest anxiety, depression, or sleep disturbances, and others have disinhibited behavior, such as making inappropriate comments, ignoring social behavior, and neglecting personal grooming. Suicidal behavior can occur in the early stage of the disorder, when the person is more cognitively capable of carrying out the suicide plan. People with dementia are extremely susceptible to both physical and psychosocial stressors, which exacerbate their cognitive deficits and other problems.

DEMENTIA OF THE ALZHEIMER TYPE

Clients with dementia of the Alzheimer type manifest a subtle but progressively deteriorating clinical course. Symptoms reveal a loss of intellectual capacities, such as memory, judgment, cognition, orientation, and consistency of mental processes. There are changes in personality, typified by depression, agitation, and confusion. Also evident are behavioral changes, manifested by hyperactivity, wandering, pacing, floccillation (aimless picking at clothing or bed covers), and sleep disturbances. These conditions worsen with time and interfere with personal, social, occupational, and leisure functioning. Eventually, the ability to perform self-care activities is lost. In dementia of the Alzheimer type, cognitive deficits aren't due to disorders of the central nervous system (Parkinson's disease or cerebrovascular disease), systemic conditions (human immunodeficiency virus infection) that are directly linked to dementia, or substance-induced conditions. The disorder affects both women and men. The onset of the early type typically occurs at age 65 or earlier, and the onset of the late type is after age 65. (For further information, see Common Physiologic Causes of Cognitive Disorders.)

Low levels of the neurotransmitter acetylcholine have been found in the brains of clients with dementia. Several other neu-rotransmitters, namely norepinephrine, serotonin, aspartate, gamma-aminobutyric acid, and glutamate, are noted to be at low levels in AD clients. Research indicates that AD is linked to genetic errors on chromosomes 14, 19, and 21. Chromosome 14 is connected to early onset AD, and chromosome 19, to late onset AD. Clients with AD develop neurofibrillary tangles, abnormal protein bundles found in the brain. In addition, there are sphere-shaped protein structures called plaques that are space-occupying lesions. The tangles attack the inside of neurons and the plaques attack the axons and dendrites, thereby causing deterioration of the brain. Researchers have established a link between the gene coding for brain protein found in the plaques and tangles on chromosome 21.

Medications are used to manage the underlying causes of the client's delirium, current health condition, and symptoms associated with an agitated state.

COMMON PHYSIOLOGIC CAUSES OF COGNITIVE DISORDERS

Endocrine dysfuntion Addison's disease Cushings’s disease Diabetic ketoacidosis Hypoglycemia Hypothyroidism Parathyroid disease Central nervous system disorders Alzheimer’s disease Amyotropyhic Lateral sclerois Brain abscess or tumor Cerebrovascular disease Epilepsy Huntingtons’s disease Meningitis Multiple sclerosis Parkinson’s disease Pick’s disease Septicmia Subdural hematoma Syphilis

Cardiac and vascular disorders Subacute bacterial endocarditis Heartfallure Hjypertension Cerebral atherosclerosis Nutritional and deficiency states Iron deficiency Penicious anemia Folic acid deficiency Vitamin B (thiamine) deficiency Vitamin B12 (cyanocobalamin) deficiency Other conditions Acquired immunodeficiency syndrome Liver disease Anoxia Lung disease Kidney disease Pancreatic or hepatic encephalopathy Chronic substance abuse Heavy metal poisonings

The decline in functioning is categorized in three distinct symptom stages: early or amnestic stage, middle or dementia stage, and late or vegetative stage. (See Symptoms of Alzheimer's Disease)

SYMPTOMS OF ALZHEIMER’S DISEASE

Early or Amnestic Stage Anxiety or fear Periods of forgetfulness Irritability, moodiness, or personality changes Increasing periods of confusion Minor dfffticult with actives of daily living (ADLs) Difficulty sleeping Middle or Dementia Stage Short-term memory loss Unmanageable confusion Decreased concentration and comprehension Difficulty with decision making Motor restlessness (sundown syndrome) Repetitive behaviors Difficulty recognizing people Cycle of depression, blame, and anger Bowel and bladder incontinence Late or Vegetative Stage Late or Vegetative Stage Long-term memory loss Regression Mutism or verbal communication of only sounds Inability to perform ADLs Difficulty swallowing Weight loss Inability to recognize self or others

COMMUNICATION STRATEGIES

• Approach the client from the front rather than from behind to prevent a startle response.
• Orient and introduce yourself to the client as appropriate.
• Talk in a quiet, calm, and unhurried manner.
• Gently confront clients about their misperceptions after a trust relationship is established.
• Use touch judiciously, and ask permission before touching the client.
• Break down each request into small, achievable steps.
• Be aware of the client's use of confabulation (making up that which can't be remembered).
• Make statements specific and focused ("You need to put on your coat"), rather than abstract.
• Communicate nonverbally when the client has lost the use of language.

NURSING DIAGNOSIS: RISK FOR TRAUMA

Probable Causes	Defining Characteristics
Physiological alteration in structure or functioning of the brain Endocrine disorders Neurosensory changes Metabolic disturbance Circulatory disturbance	Gait and coordination difficulties Agitated behavior Wandering behavior Disorientation and confusion Inability to use sharp instruments and complicated appliances

Long-Term Goal
The client will not injure self or sustain any accidental injury.

Short-Term Goal #1: The client and family will remove or secure all potential hazards in the home environment.

Interventions and Rationales

• Make the environment safe by removing all potentially hazardous objects, decreasing noise, and using a clock, calendar, and familiar objects to promote a sense of security. Environmental management is a priority if the client is to remain in the community-setting as long as possible.
• Identify safe places for the client in the home or agency setting and keep these safe places clutter-free and hazard-free. Safety-is promoted by removing clutter and hazardous items, such as loose throw rugs, portable heaters, and complicated appliances. from the client's environment.
• Store all harmful materials, such as drain cleaners, insecticides, and furniture polish, in safe, locked, and labeled containers. This action prevents accidental ingestion of or contact with toxic substances.
• Remove all nonprescription medications, such as bottles of aspirin and cough syrup, and all out-of-date or potentially dangerous prescription items, such as barbiturates and narcotics. This action prevents the client from having access to potentially dangerous medications, inadvertently taking them incorrectly, and using them to commit suicide.
• Put labels on rooms and doors, using printed names or a picture of an object. This serves as a guide to the environment for the cognitiveiy impaired client.
• As appropriate, install safety bars, other safety equipment, and alarms for beds, chairs, and doors. Safety equipment may prevent falls: alarms alert caregivers of client movement and allow for prompt intervention.

Short-Term Goal #2: The client will participate in enjoyable routine activities with close supervision.

Interventions and Rationales

• Accompany the client during ambulation, and take the client outdoors for exercise when possible. Ambulation and exercise promote circulation and overall physical well-being.
• Notify appropriate others (police, hospital, neighbors) of the possibility of the client's wandering. An established community-awareness of the client's tendency to wander helps promote the client's safe return.
• Have the client wear medical identification. Easy identification is important for the client's safety.
• If the client smokes, supervise this activity closely and never allow the client to have a lighter or matches. This eliminates the possibility of sustaining a burn or starting a fire.
• Minimize and supervise closely any food or beverage preparation Because of impaired judgment, the client may injure himself if permitted to manipulate sharp instruments and cooking appliances.

NURSING DIAGNOSIS: SELF-CARE DEFICIT IN BATHING/HYGIENE, DRESSING/GROOMING, FEEDING, OR TOILETING

Probable Causes	Defining Characteristics
Physiologic problems Attention deficits Memory impairment or confusion Depression or feelings of hopelessness Inability to concentrate on or complete a task	Disorientation Difficulty recognizing objects used for care Dirty or inappropriate clothing Poor grooming of hair or nails Uneaten, spoiled, or uncooked food

Long-Term Goal
The client will maintain an appropriate level of participation in self-care as evidenced by performing activities of daily living.

Short-Term Goal #1: The client will demonstrate adequate food and fluid intake.

Interventions and Rationales

• Observe and assess the client in meal preparation activities and actual dining. Observing the client provides information about the best foods for the client to handle and how to set up each meal tc promote maximum client participation.
• Monitor food and fluid intake. The client may not eat or drink adequately due to confusion, disonentation, or lack of coordination in manipulating utensils.
• Provide appropriate adaptive supports, devices, and space for handling food and utensils. Special devices may enhance the client's ability to manipulate food and feed self
• Weigh the client on a weekly basis. Monitoring weight is a check on nutrition and hydration status.
• Prevent the client from eating nonfood items. The client may se unable to differentiate edible food from inedible objects and may inadvertently harm self

Short-Term Goal #2: The client will maximize participation in personal hygiene, toileting, and grooming activities.

Interventions and Rationales

• Encourage the client to perform all grooming and personal hygiene activities that can be accomplished safely and without expending excessive energy. Participation in self-care activities promotes self-esteem and maintains tone of muscle groups.
• Have specialized equipment installed, such as a raised toilet seat or safety bars. The availability of specialized equipment enhances the performance of bathing and toileting activities.
• Have the client wear clothes rather than pajamas and robe. The client needs to maintain a positive sense of self
• Provide clothing that is easy to manipulate, such as garments with elastic waistbands and Velcro fasteners. Easy to manipulate clothing facilitates independence in dressing.

Short-Term Goal #3: The client will maintain a schedule that includes adequate sleep, rest, and activity.

Interventions and Rationales

• Establish an activity schedule that provides for rest periods following activities. It is important to prevent the client from becoming exhausted.
• Monitor the client's activity tolerance and, if possible, develop a daily exercise program. Exercise has positive cardiovascular effects and promotes emotional well-being.
• Provide opportunities for the client to engage in simple and familiar social and task-oriented activities. Participation in activities promotes socialization. orientation, and enjoyment.
• Determine how exercise, rest periods, and activities impact on the client's ability to sleep. By monitoring sleep-rest patterns, the nurse can determine the best conditions for promoting sleep.

NURSING DIAGNOSIS: CAREGIVER ROLE STRAIN

Probable Causes	Defining Characteristics
Unsafe situations involving the client Increased client aggression or agitation Diminishing family support Inability to obtain respite care Dwindling financial resources	Verbalized feelings of guilt and of being overwhelmed Anger or depression Lack of patience Possibly neglect or abuse of client Loss of personal and social life

Long-Term Goal
The family will verbalize that they feel supported and can cope with the deterioration and anticipated loss of their family member.

Short-Term Goal #1: The family members will discuss their conflicting or ambivalent feelings about the client.

Interventions and Rationales

• Assist family members to identify and discuss their feelings about the situation. It is common for people to feel confused, feaful, guilty, and grief-stricken when a family member is diagnoses with AD.
• Discuss situations that are particularly stressful for caretakers such as dealing with the client's suspicion, anxiety, and hostile behavior. Teaching the family how to manage these distressing behaviors promotes control of the situations.
• Educate family members about how to handle the declining capabilities of their loved one. Knowledge and the ability to handle situations reduce anxiety and feelings of helplessness.
• Arrange for family therapy to preclude a stressful situation from escalating into a crisis. A family in crisis or on the verge of crisis needs assistance initiating coping behaviors.
• Discuss with the family the need to obtain power of attorney as the client's condition continues to decline. Planning gives the family time to discuss the best course of action to take as the clients need for care increases.

Short-Term Goal #2: The family will develop a resource network and become aware of how to access community resources to obtain support and guidance.

Interventions and Rationales

• Discuss the resources needed to provide safe, adequate care. Human and financial resources must be budgeted for and instituted before effective care can begin.
• Formulate a plan to obtain assistance from other family members, neighbors, and friends as appropriate. Delegation of tasks and responsibilities decreases the caregivers energy expenditure and level of anxiety.
• Talk to the caregiver about the need to establish a plan for maintaining personal well-being, including rest, exercise, and recreation. Caregivers need to know that daily stressors and erasures increase their susceptibility to illness.
• Teach caregivers how to avoid stress and practice stress management skills. Caregivers must know how to manage stressors and prevent themselves from experiencing exhaustion from over functioning and overload of responsibilities.
• Develop an alternative plan of care for the client if the caregiver should become ill. Emergency backup plans must be in place so that they can be mobilized if the need occurs.
• Obtain a reference list of available medical services, especially home health and respite care. The family's ability to access necessary services enables the client to remain in the community and delays the need for institutionalization.

THERAPIES

Medical treatment for dementia is palliative and supportive. Group therapy is based on the premise that care must promote the highest level of functioning possible for the client. The major areas to be addressed are self-care and social and family relationships.

Medical/Biological Interventions

• Perform a physical examination and diagnostic tests to identify possible causes of dementia.
• Medically treat all physiologic problems.
• Symptomatically treat depression, anxiety, and insomnia.
• Maintain physical health, and support optimal level of functioning.

Group Therapy

• Promote orientation to environment, and briefly discuss pertinent current events.
• Discuss the here and now for brief periods. Encourage reminiscing therapy, which focuses on sharing past memories.
• Limit talk to familiar and meaningful things to reinforce reality and encourage client participation.
• Assist participants to talk about their past as a way to increase self-esteem.
• Encourage clients to talk to one another.

MEDICATIONS

Medications are administered to assist in managing anxiety, depression, aggression, and paranoid behavior, as well as to replace neurochemicals in the brain.

• Tricyclic antidepressants may be used to treat depression.
• Antipsychotics, such as haloperidol (Haldol) and rispendone (Resperdal), may be used in low doses to treat anxiety and agitation.
• Vasodilators are often used to increase cerebral circulation and enhance cognition.
• Tacrine (Cognex) and donepezil (Aricept) inhibit the breakdown of acetylcholine and are useful in slowing the progression of symptoms in clients with early- or middle-stage AD.
• Medications that stimulate neurotransmitter action are being researched. (See Appendix D for medication information.)

FAMILY CARE

• Provide the family with information and emotional support throughout the three phases of dementia.
• Assist the family to develop a social support network.
• Teach the family how to manage or advocate for the client s self-care needs.
• Identify community resources, skilled nursing and homemaker services, and support groups for caretakers and other family members.
• Evaluate the home environment, and assist the family to make necessary changes for safety.
• Encourage family members to verbalize feelings, concerns, and frustrations about the situations they face.
• Assist family members with anticipatory grieving for the loss of their loved one.

Amnestic Disorder

DSM-IV CATEGORIES

294.0 Amnesic disorder due to ... [indicate the general medical condition]

__._ Substance-induced persisting amnestic disorder 294.8 Amnestic disorder NOS

People with an amnestic disorder display an inability to learn new information or the inability to recall already learned information and past events. This memory problem negatively influences the person's social and occupational functioning in that spontaneous recall is severely impaired. Some people with an amnestic disorder may remember the remote past but not the recent past. The ability to repeat a string of information such as a digit span is not usually impaired. The disorder is not diagnosed if other cognitive deficits, such as aphasia, apraxia, and agnosia are present. People with an amnestic disorder may require closely supervised living accommodations to assure that basic care needs are met. The age of occurrence varies based on the pathophysiologic condition causing the disorder. Examples of causes of amnestic disorder are traumatic brain injury, cerebrovascular events, prolonged substance use, sustained nutritional deficiency, and carbon monoxide poisoning.

Amnesia is typically seen when there is bilateral damage to the temporal lobe of the brain or to other parts of the limbic system. Depending on where the brain damage occurs, clients with amnestic disorder can manifest various symptoms. Memory loss is extensive after a cerebral injury. In some cases, memory improvement occurs within the first 2 years post trauma; with most injuries, memory loss is permanent.

COMMUNICATION STRATEGIES

• Frequently orient clients to time and place only because they usually maintain orientation to self
• Explain procedure or routine immediately before carrying it out.
• Break down each request into small, achievable steps.
• Be aware of the client's use of confabulation (making up that which can't be remembered).
• Make statements specific and focused ("You need to put on your coat"), rather than abstract.
• Focus conversation on topics initiated by the client.

NURSING DIAGNOSIS: KNOWLEDGE DEFICIT AND POSSIBLE DENIAL OF BASIC NEEDS RELATED TO SEVERE MEMORY IMPAIRMENT

Probable Causes	Defining Characteristics
Pathophysiologic condition History of prolonged substance use Lack of insight into memory problem Lack of perception of basic needs Underlying fears	Refusal of self-care assistance Emotional blandness Agitation Denial of medical problem

Long-Term Goal
The client will verbalize awareness of physiological health problem and acknowledge the need to obtain assistance from the nurse.

Short-Term Goal #1: The client will identify his current health situation.

Interventions and Rationales

• Spend time with the client, and talk about the client's health and self-care needs. Time spent talking with the nurse facilitates the client's ability to acknowledge basic concerns.
• Encourage the client to discuss his current medical condition with the nurse. Discussion of his medical condition helps the client express concerns and. reinforces the reality of his current health situation.
• Provide the client with information to clarify or correct misconceptions about health. Clear, simple, factual information increases the client's ability to understand current health condition.

Short-Term Goal #2: The client will demonstrate a working relationship with the nurse to meet self-care needs.

Interventions and Rationales

• Spend time talking with the client about daily self-care needs. This action enhances the client's awareness of personal needs ana the necessity of performing care on a daily basis.
• Instruct and assist the client as necessary with self-care activities. Coaching and assisting the client's individual efforts at self-care promote the client's highest level of independent functioning.
• Provide additional opportunities for the client to interact with the nurse about concerns related to self-care activities. Opportunities to discuss self-care needs enable the nurse and the client to see what areas the client needs assistance with as well as identify areas of self-care competency.

NURSING DIAGNOSIS: SELF-CARE DEFICIT IN BATHING/HYGIENE, DRESSING/GROOMING, FEEDING, ORTOILETING

Probable Causes	Defining Characteristics
Physiologic problems Memory impairment Disinterest in self and environment Agitation or confusion Inability to concentrate on or complete a task	Disorientation Body odor due to failure to bathe Dirty or inappropriate clothing Poor grooming of hair or nails Eating uneaten, spoiled, or uncooked food

Long-Term Goal
The client will maintain an appropriate level of participation in self-care as evidenced by performing activities of daily living.

Short-Term Goal #1: The client will demonstrate adequate food and fluid intake.

Interventions and Rationales

• Observe and assess the client in meal preparation activities and actual dining. Observing the client provides information about f.e best foods for the client to handle and how to set up each meal tc promote maximum client participation.
• Monitor food and fluid intake. The client may not eat or drink adequately due to confusion, disorientation, and lack of coordination in manipulating utensils.
• Provide appropriate adaptive supports, devices, and space for handling food and utensils. Special devices enhance the clients ability to manipulate food and feed self
• Weigh the client on a weekly basis. Monitoring weight is a check on nutrition and hydration status.

Short-Term Goal #2: The client will maximize participation in personal hygiene, toileting, and grooming activities.

Interventions and Rationales

• Encourage the client to perform all grooming and personal hygiene activities that can be accomplished safely and without expending excessive energy. Participation in self-care activities promotes self-esteem and maintains tone of muscle groups.
• Have specialized equipment installed, such as a raised toilet seat and safety bars. The availability of specialized equipment enhances the performance of bathing and toileting activities.
• Have the client wear clothes rather than pajamas and robe. The client needs to maintain a positive sense of self
• Provide clothing that is easy to manipulate, such as garments with elastic waistbands and Velcro fasteners. Easy to manipulate clothing facilitates independence in dressing.

Short-Term Goal #3: The client will maintain a schedule that includes adequate sleep, rest, and activity.

Interventions and Rationales

• Establish an activity schedule that provides for rest periods after activities. It is important to prevent the client from becoming exhausted.
• Monitor the client's activity tolerance, and if possible, develop a daily exercise program. Exercise has positive cardiovascular effects and promotes emotional well-being.
• Provide opportunities for the client to engage in simple and familiar social and task-oriented activities. Participation in activities promotes socialization, orientation, and enjoyment.
• Determine how exercise, rest periods, and activities impact on the client's ability to sleep. By monitoring sleep-rest patterns, the nurse can determine the best conditions for promoting sleep.

THERAPIES

Medical treatment for a client with an amnestic disorder is supportive. Group therapy is based on the premise that care must promote the highest level of functioning possible for the client. The major areas to be addressed in therapy are self-care and sc-cial and family relationships.

Medical/Biological Interventions

• Perform a physical examination and diagnostic tests to identify pathophysiologic processes and treat medical conditions.
• Symptomatically treat depression, anxiety, and related problems.
• Maintain physical health, and support an optimal level of functioning,

Group Therapy

• Promote orientation to time and environment.
• Discuss the here and now for brief periods.
• Limit talk to familiar and meaningful things to reinforce reality and encourage client participation.
• Encourage clients to talk to one another.

MEDICATIONS

Medications are administered to assist in managing anxiety, depression, aggression, and paranoid behavior, as well as to replace neurochemicals in the brain.

• Tricyclic antidepressants may be used to treat depression.
• Antipsychotics may be used in low doses to treat anxiety and agitation.
• Vasodilators are often used to increase cerebral circulation and enhance cognition.
• Tacrine (Cognex) and donepezil (Aricept) inhibit the breakdown of acetylcholine.
• Medications that stimulate neurotransmitter action are being researched. (See Appendix D for medication information.)

FAMILY CARE

• Provide the family with information and emotional support.
• Assist the family to develop a social support network.
• Teach the family how to manage or advocate for the client s self-care needs.
• Identify community resources, skilled nursing and homemaker services, and support groups for caretakers and family members.
• Evaluate the home environment, and assist the family to make necessary changes for safety
• Encourage family members to verbalize feelings, concerns, and frustrations about the situations they face.
• Assist family members with anticipatory grieving for the loss or their loved one.