updated24-25 NUR 303 Lecture 3 -common health problems of older people(5-6)

Delirium is a frequent cause and a serious complication of hospitalization in older adults.

Major barriers to effective treatment of delirium include under-recognition of the syndrome and poor understanding of the underlying pathophysiology.

Management strategies for delirium focus on prevention and symptom management.

The key components of a thorough assessment for delirium include:

1. Thorough medical history: This involves understanding the patient's usual mental state, any recent operations, and potential infections.

2. Assessment tools:

   • General cognitive assessment tools: Examples include MMSE (Mini-Mental State Examination) and MoCA (Montreal Cognitive Assessment).
   • Delirium-specific assessment tools: An example is the Confusion Assessment Method (CAM).

3. Self-reports or caregiver reports: Gathering information on any changes in cognitive function from the patient or their caregivers.

The diagnosis of delirium by CAM requires the presence of:

1. Feature 1: Acute Onset of Changes or Fluctuations in the Course of Mental Status
2. Feature 2: Inattention
3. Either Feature 3: Disorganized Thinking or Feature 4: Altered Level of Consciousness

The modifiable risk factors for delirium include:

1. Acute neurological diseases
2. Infections
3. Fracture
4. Surgery
5. Dehydration
6. Poor nutritional status
7. Emotional distress
8. Polypharmacy
9. Immobilization
10. Change of environment

The two main pathways leading to delirium are:

1. Pathway 1:

   • Hypoxemia, metabolic derangements
   • Global impairment of cerebral metabolism
   • Decreased synthesis and release of neurotransmitters
   • Result: Delirium

2. Pathway 2:

   • Drugs
   • Neurotransmitter imbalance, disruption of synaptic communication
   • Result: Delirium

Systemic inflammation contributes to delirium through the following pathway:

1. Activation of primed microglia
2. Increased cytokine levels in the brain
3. Neurotransmitter imbalance, disruption of synaptic communication
4. Result: Delirium

Dementia is NOT a normal part of aging; it is a collective name for many progressive brain syndromes characterized by drastic degeneration and death of brain cells, leading to an abnormal decline in cognitive functions.

Approximately 9.3% of adults aged 70 or above are affected by dementia.

By 2039, more than 300,000 elderly individuals aged over 60 will be suffering from dementia in Hong Kong.

The prevalence of dementia increases as people age in Hong Kong.

Dementia is an irreversible, progressive impairment in cognitive function that affects various abilities such as memory, orientation, judgement, reasoning, attention, language, and problem solving. It is an umbrella term for several neurological conditions characterized by a decline in brain function due to physical changes in the brain, and it is not the same as mental illness.

• Most common form of dementia
• Involves neurofibrillary tangles, amyloid plaque, and brain atrophy
• Slow onset of symptoms and steady decline in activities of daily living (ADLs)

• Previously called multi-infarct dementia
• Associated with cardiovascular risk factors such as:
  • Hypertension (HT)
  • Diabetes Mellitus (DM)
  • High blood cholesterol and lipid levels
  • Arrhythmia
  • Smoking
• Many subtypes depending on the location of vascular damage in the brain

• Caused by a buildup of Lewy's body proteins in the brain
• Rapid shifts in mood and behaviors
• Symptoms include:
  • Visual hallucinations
  • Tremor and rigidity
  • Paranoia and delusions

• Originally called Pick's Disease
• Affects individuals in their mid-50s
• Associated with frontal and temporal anterior lobe atrophy
• Behavioral changes and language problems are more obvious, while visuospatial and memory skills remain intact

A common early sign of dementia is a decline in short-term memory, which may manifest as forgetting names or appointments but later remembering them.

Dementia can lead to difficulty with speech, writing, or comprehension, creating a communication barrier for the individual.

Signs of disorientation in individuals with dementia include confusion about time or place.

Individuals with dementia may experience difficulty completing everyday tasks and a decline in planning and problem-solving abilities.

Dementia can lead to withdrawal from work or social activities, impacting social interactions.

Individuals with dementia may exhibit changes in mood and personality, which can be noticeable to family and friends.

Dementia can cause trouble understanding visual information, such as objects, people, and spatial relationships, which may be compounded by age-related vision changes like cataracts.

The key components of clinical judgment in dementia assessment include:

1. History Taking (from the client and caregivers)
2. Physical Examination
3. Cognitive Status Assessment (using tools like MMSE, MOCA, ADAS-Cog)
4. Functional Assessment (including ADL & IADL, gait, and balance)
5. Radio-diagnostic Imaging (CT scan, MRI, PET scan)
6. Laboratory Tests (CBP, biochemistry, vitamin B12, thyroid function)
7. Determine Underlying Etiology
8. Identify Treatable Conditions
9. Decide on Treatment Modality
10. Assess Levels of Care

Common cognitive status assessment tools used in dementia evaluation include:

• Mini-mental Status Examination (MMSE)
• Montreal Cognitive Assessment (MOCA)
• Alzheimer's Disease Assessment Scale (ADAS-Cog)

The types of radio-diagnostic imaging utilized in the assessment of dementia include:

• Computerized Tomography (CT) scan
• Magnetic Resonance Imaging (MRI)
• Positron Emission Tomography (PET) scan

Important laboratory tests in the assessment of dementia include:

• Complete Blood Picture (CBP)
• Biochemistry tests (RFT, LFT, lipid profile, +/- genetic studies)
• Vitamin B12 levels
• Thyroid function tests

The purpose of determining underlying etiology in dementia assessment is to identify any treatable conditions and to guide the appropriate treatment modality and levels of care required for the patient.

The key pathological features of Alzheimer's Disease include:

1. Tangling of Tau-protein in neurofibrils
2. Deposit of β-amyloid protein plaques in neurons
3. Shrinkage of the cerebral cortex
4. Shrinkage of the hippocampus
5. Enlarged ventricles

Symptoms include:

• Reading problems
• Poor object recognition
• Poor direction sense

In Moderate Alzheimer's, the disease spreads to the frontal lobe of the brain, affecting functions such as judgment and attention.

The primary symptom of Mild Cognitive Impairment is short-term memory loss.

Symptoms include visual problems as the disease spreads to the occipital lobe.

• Trouble remembering recent events.
• Difficulty managing finances.
• Difficulty completing familiar tasks.
• Losing track of dates and the passage of time.
• Difficulty with vision and spatial relations, leading to getting lost.
• Problems with speaking and writing words.
• Forgetfulness and misplacing things.
• Social withdrawal from family and friends.
• Changes in mood or personality (confusion, depression, suspiciousness, anxiety).
• Often repeating questions and statements.
• Trouble with driving, confusing pedals and traffic signals.

• Behavioral problems such as anger, paranoia, anxiety, and suspiciousness.
• Wandering and getting lost.
• Repetitive behaviors, often repeating things.
• Anxiety, particularly in the late afternoon and early evening (sun-downing).
• Eating problems, including loss of table manners.
• Needs assistance with bathing, dressing, and personal care.
• Incontinence.
• Hoarding behaviors.
• Inappropriate behavior.
• Violent behavior.
• Increased difficulty with speech and recall.
• Loss of coordination, leading to shuffling and more falls.
• Stops recognizing family and friends.

• Loses ability to communicate.
• Loses ability to smile.
• Inability to recognize people, places, and things.
• Requires full assistance with dressing, bathing, and personal care.
• Loses ability to chew and swallow.
• Eventually loses ability to walk.
• Sleeps a lot.
• May experience seizures.
• May have strokes.
• Incontinence and bowel problems.
• Weight loss.

The genetic risk factors for Alzheimer's Disease include the APOE-4 gene and a family history of the disease.

Approximately 2/3 of individuals diagnosed with Alzheimer's Disease are women, indicating a significant gender influence on risk.

Environmental risk factors for Alzheimer's Disease include air pollution, city combustion waste, and water impurities such as aluminum toxicity.

Lifestyle factors that contribute to the risk of Alzheimer's Disease include smoking, alcohol consumption, poor sleep, unhealthy diet, lack of exercise, and stress.

The risk of developing Alzheimer's Disease increases with age, with a 3% risk for those aged 65-75 and a 32% risk for those over 85.

Chronic diseases associated with an increased risk of Alzheimer's Disease include diabetes mellitus (DM), hypertension (HT), obesity, hypercholesterolemia, and dyslipidemia.

Cognitive factors that are risk factors for Alzheimer's Disease include a low education level and less cognitive reserve.

Head injuries are considered a risk factor for Alzheimer's Disease, as they can lead to brain cell damage.

Vascular Dementia (VaD) is the second most common form of dementia characterized by:

• Clinical evidence of local brain damage
• Abrupt onset and stepwise deterioration
• Evidence of stroke, hypertension, and other cardiovascular disease risk factors.

The subtypes of Vascular Dementia include:

Yes, symptoms can be similar in both conditions, and it is possible for an individual to have both Vascular Dementia and Alzheimer's Disease simultaneously.

The common symptoms of vascular dementia include:

• Inappropriate Behavior
• Personality Change
• Memory Loss
• Hallucination
• Poor Judgement
• Misplacing Things
• Difficulty in Organizing
• Reduced Language Skills

The primary signs and symptoms of Lewy Body Dementia include:

• Fluctuating cognition
• Change in personality and mood
• Visual hallucinations
• Paranoia or delusions (which can change day by day)
• Sleep disorders

Additionally, symptoms related to Parkinsonism include:

• Postural tremor and unsteady gait
• Rigidity and mobility impairment

The symptoms of Lewy Body Dementia are caused by the deposition of abnormal proteins (alpha-synucleins) in the neurons, leading to apoptosis (cell death). This affects different parts of the brain, resulting in both dementia-related symptoms and Parkinsonism symptoms.

Frontotemporal Dementia (FTD) is a group of disorders caused by the progressive loss of nerve cells in the frontal and temporal lobes of the brain. The exact etiology is unknown, but it may involve genetic mutations.

In the early stages of Frontotemporal Dementia (FTD), short-term memory is often not affected. However, symptoms can include:

• Change in personality
• Impulsive behaviors
• Poor insight and judgement
• Difficulty in concentration and thinking
• Language disturbances, such as progressive non-fluent aphasia
• Poor mobility coordination

• Early, insidious short-term memory loss
• Language deficits & spatial disorientation
• Later personality changes

• Stepwise decline
• Early executive dysfunction
• Cerebral infarction &/or deep white matter changes on neuroimaging

• Early personality changes
• Apathy, disinhibition & compulsive behavior
• Frontotemporal atrophy on neuroimaging

• Visual hallucinations
• Spontaneous parkinsonism
• Fluctuating cognition

Common blood tests include:

• Drug and alcohol tests (toxicology screen)
• HIV tests
• Syphilis tests

A lumbar puncture is performed to:

• Obtain cerebrospinal fluid
• Analyze the fluid for Alzheimer's disease proteins or to check for certain infections and inflammatory conditions

CT is primarily used to identify signs of stroke or a brain tumor.

MRI is used to confirm the type of disease causing dementia, including:

1. Assessing if blood vessels are damaged, which is relevant in vascular dementia.
2. Showing which parts of the brain are shrinking.

PET can help identify the presence of a brain tumor.

There is no curative treatment for Alzheimer's disease.

Drugs are used to temporarily slow down the progression of symptoms of Alzheimer's disease and to manage behavioral symptoms.

The medications commonly used for memory loss include:

1. Donepezil (Aricept)
2. Rivastigmine (Exelon)
3. Memantine (Ebixa)
4. Galantamine (Reminyl)

Examples of non-pharmacological interventions include:

1. Reality Orientation: Helps individuals with dementia to stay connected to their environment and reality.
2. Reminiscence Therapy: Involves discussing past experiences to enhance memory and emotional well-being.
3. Multisensory Stimulation: Engages multiple senses to improve cognitive function and emotional response.
4. Alternative Therapies: Such as music therapy and aromatherapy, which can provide comfort and improve mood.
5. Cognitive Training: Focuses on enhancing attention, eye-hand coordination, and daily living skills.

The commonly used medications for managing behavioral symptoms include:

1. Antidepressant medications
2. Antipsychotic medications
3. Anti-anxiety drugs

The purpose of a Comprehensive Geriatric Assessment in dementia care is to:

1. Determine the client's levels of dependency.
2. Identify the client's care needs.
3. Assess the progression of dementia based on the 7 stages.

Common assessment tools include:

1. Abbreviated Mental Test (AMT)
2. Mini-Mental State Examination (MMSE)
3. MoCA (Montreal Cognitive Assessment)

These tools assess memory, problem solving, language skills, math skills, sensory response, and reflexes.

• Stay in regular routine
• Use visual prompts/cues (e.g., clock, watch, calendar)
• Utilize memory aids (e.g., drawing board, notepads, lists)
• Focus on one task at a time
• Break down tasks into small steps
• Simplify the home environment with labeling/pictures
• Keep items in the same place
• Build repetitive skills and drills
• Engage in reminiscence with old-time pictures, photos, movies, music
• Provide cognitive stimulation (e.g., chess, mahjong, sudoku)
• Implement reality orientation

The key principles of assistance in supporting ADLs include:

1. Respect & Dignity: Treating clients with respect and maintaining their dignity.
2. Safety: Ensuring a safe environment for the client.
3. Engaging Client: Actively involving the client in their care.
4. Use Assistive Devices: Utilizing tools that aid in daily activities.
5. Incremental & Step by Step: Providing assistance in a gradual manner.
6. Motivation: Encouraging and motivating the client to participate in activities.

1. Empathy: Understand their world from their perspective.

2. Initial Assessment: Identify the individual's status and needs.

3. Reminiscence Therapy: Journal about joyful past experiences.

4. Self-Actualization Activities: Provide opportunities for activities like craftwork, painting, and calligraphy.

5. Sense of Fulfillment: Elicit feelings of fulfillment from past achievements and roles.

6. Integration Activities: Enhance channels for integrating the inner self with the outer world through music therapy, reflective writing, and art therapy.

7. Sensory Stimulation: Create sensory experiences with pet therapy, tactile exercises, and aromatherapy.

8. Social Interaction: Promote interaction with family, peers, and young people.

9. Drug Therapy: Administer prescribed medications as needed.

• Continuous support is essential: you're not alone
• Advice on home-safety design
• Use of assistive devices to support more independent living
• Assess and identify available and appropriate caregivers
• Train caregivers in areas of the client's mobility, transfer, nutrition, communication, and orientation.
• Establish a support group for caregivers to talk and relieve stress
• Arrange respite care or day care to give caregivers a break and avoid burnout
• Discuss any need for financial support and assist with applications

• Quit Smoking
• Weight Management
• BP Control / DM Control
• No Alcohol
• Healthy Diet
• Enjoy social activity
• Physical Exercise
• Brain Games

• Hearing Loss
• Hypertension
• Obesity
• Smoking
• Depression
• Diabetes

• Education
• Physical Activity
• Social Contact

1 in 3 cases of dementia could be prevented by addressing these lifestyle factors.

The primary goal is to maximize functional abilities by supporting all losses in a prosthetic manner.

Caregivers can support clients by:

1. Establishing a caring relationship.
2. Teaching caregivers to observe and evaluate verbal and nonverbal responses.
3. Identifying triggers related to discomfort or stress reactions.
4. Modifying the environment to support losses and promote safe function.
5. Evaluating care routines and responses to plan care effectively.

To encourage self-care, caregivers should:

1. Offer choices to the client.
2. Explain all actions taken.
3. Avoid rushing or forcing the person to do something.

Caregivers should receive ongoing education, support, care, and problem-solving assistance to effectively manage the needs of clients with BPSD.

Common triggers include:

1. Hunger, thirst, toileting needs
2. Feeling too hot/too cold
3. Boredom
4. Pain or discomfort
5. Sleep disturbances
6. Environmental overstimulation or understimulation
7. Changes in environment or person
8. Certain people
9. Certain activities (meals, baths)
10. Loss of control; being forced to do something
11. Restraint

1. Avoid provoking situations
2. Intervene early before escalation
3. Remain calm; speak in a soft voice
4. Approach slowly from the front
5. Avoid touching initially; wait until the person is calmer
6. Stay at eye level with the person
7. Distract the person
8. Avoid rational arguments
9. Avoid physical restraint if at all possible
10. Identify and address unmet needs (food, fluid, toileting)

1. Remain calm during the process.
2. Use a soft voice to communicate.
3. Choose a time when the person is most rested and least confused.
4. Consider the person's lifelong preferences regarding bathing:
   • Shower vs. bath
   • Morning vs. evening
5. Maintain a leisurely pace and avoid rushing.
6. Premedicate with analgesics if there is pain with movement.
7. Allow the person to wear underwear or a gown if desired.
8. Avoid spraying water directly on the head or face.
9. Use distraction techniques such as conversation, snacks, or music.
10. After bathing, give praise for their clean appearance.

1. Assist the person to keep track of personal items.

2. Avoid defensiveness if accused.

3. Do not argue with the person.

4. Maintain a simple, noncluttered environment.

5. Avoid whispering in front of the person.

The classifications of ISB include:

1. Sex talk: Foul language not consistent with premorbid personality.
2. Sexual acts: Such as masturbation or exposing oneself in private or public places.
3. Implied sexual acts: Requesting unnecessary genital care.

If a person is disrobed, the intervention is to offer clothing to them.

If a person is masturbating, the following steps should be taken:

1. Avoid laughing, scolding, or confrontation.
2. Guide the person to a private place.
3. Distract the person.

Wandering is a behavioral problem associated with dementia, particularly prevalent in the middle or later stages of the disease. It can occur during the day or at night and is characterized by aimless or purposeful motor activity, such as pacing up and down. This behavior often leads to social issues, including getting lost, leaving safe environments, or intruding into inappropriate places.

Common characteristics of wandering in dementia patients include:

1. Increased motor activity: Patients may pace up and down.
2. Aimless or purposeful movement: The activity may not have a clear purpose.
3. Low social interaction: Wandering can be associated with reduced engagement with others.
4. Occurrence at any time: Wandering can happen during the day or at night.
5. Management challenges: It poses significant challenges in both home and institutional settings.

Wandering in dementia patients can lead to several social problems, including:

• Getting lost: Patients may wander away from familiar areas.
• Leaving safe environments: They may exit secure settings, increasing the risk of harm.
• Intruding into inappropriate places: Wandering can result in entering areas where the patient does not belong, causing disturbances or safety concerns.

• Visuospatial impairments
• Anxiety and depression
• Poor sleep patterns
• Unmet needs
• A more socially active and outgoing premorbid lifestyle

1. Assess for unmet needs
2. Reassure the person that he or she is in the right place
3. Use identification bracelets (in case he or she gets lost)
4. Place alarms on the person and/or doors to detect elopement
5. Provide a safe wandering 'path'
6. Provide alternative activities
7. Minimise medication use (to reduce risk for falls)
8. Visually disguise exits
9. Provide daily exercise
10. Provide simple snack foods to be eaten 'on the run'

1. Face the older adult and make direct eye contact.

2. Gently touch the older adult, e.g., on the shoulder.

3. Call him or her by name.

4. Listen to what the older adult is communicating and the feelings expressed.

5. Identify the agenda, plan of action, and emotional needs that emerged from the agenda.

6. Respond to the expressed feeling.

7. Repeat specific words or phrases; state the need or emotion.

8. Distract the older adult, e.g., by talking.

9. Orientate or redirect the older adult.

10. Call for help if redirection fails.

Strategies to visually disguise exits include:

1. Creative Murals: Painting murals that depict scenes like houses or gardens can distract from the exit door.

2. Tape Barriers: Using tape barriers can create a physical and visual obstruction to exits.

3. Signage: Implementing signs that indicate 'No Exit' can help deter wandering.

4. Decorative Elements: Incorporating decorative elements around exits to blend them into the environment can reduce their visibility.

Local community resources for dementia care support include:

1. Alzheimer's Disease International - Provides information and support for individuals affected by dementia. Visit here

2. Care Resources Connect - Offers community support specifically for dementia care. Visit here

3. Hong Kong Alzheimer's Disease Association - Focuses on providing assistance and resources for Alzheimer's patients and their families. Visit here

4. Jockey Club Centre for Positive Ageing - Aims to promote positive ageing and support for older adults, including those with dementia. Visit here

Delirium is a serious disturbance in mental abilities characterized by confused thinking and reduced awareness of the environment. It usually has an acute and rapid onset, occurring within hours or a few days.