Dementia Nursing Management

Overview

Our role in dealing with clients with dementia does not differ from our usual routine in the provision of nursing care, except for the fact that we need to value the memories that once shaped their life.

Dementia is a slow, progressive disease that is accompanied by several impairments including the cognitive, behavioral, and psychiatric aspects. According to the National Institute of Neurological Disorders and Strokes, it is a group of symptoms that is brought about by disorders that affect the brain. Memory loss is the most common symptom but it may also include some behavioural changes, language impairments, inability to solve simple problems and some may even exhibit some psychiatric symptoms – which all in all, will later on affects his or her ability to assume previous roles and capabilities.

Dementia is defined as chronic, acquired loss of two or more cognitive abilities caused by brain disease or injury. Recently, the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) recognized that dementia can be present with impairment in a single domain. For example, a client with severe expressive aphasia could be classified as having dementia.

Mild cognitive impairment (MCI) is defined by a performance that is lower than normal on objective neuropsychological cognition tests but with maintained daily functions, such as daily activities at work, at home, and in social settings, and maintained activities of daily living such as personal care.

Causes/Risk Factors

Dementia is caused by damage to the brain cells. This damage interferes with the ability of the brain cells to communicate with each, resulting in dysfunction in a person’s thinking, behavior, and feelings. Common risk factors of dementia include the following:

• Age. Aging is an important risk factor for all-cause dementia. Alzheimer’s disease (AD) affects 5 to 10% of people older than 65 years and 50% of those aged 85 years.
• Genetics. AD is the most common type of dementia and has a strong genetic component, involving both common and rare genetic variants. Those who have parents or siblings diagnosed with dementia have a higher risk factor of developing the same disease than people who do not have any family history of dementia.
• Ethnicity. Older African Americans are twice more likely to have dementia than Whites. Hispanics are 1.5 times more likely to develop dementia than Whites.
• History of depression. People who are depressed have more trouble remembering things, and clients with a history of depression or midlife stress seem to have an elevated risk of dementia.
• Hypertension and stroke. Increased blood pressure is the single most important risk factor for stroke, which can lead to the development of vascular dementia. Hypertension can also become a risk factor for AD. stroke is the single most important risk factor for vascular dementia and there is some evidence that it can also increase the risk for Alzheimer’s disease.
• Sex. Most women are affected by AD than men. Vascular dementia, however, is more common in men than in women. Increased longevity of women could be one of several reasons.
• Smoking. Smoking is a potential risk factor for developing Alzheimer’s disease. It also affects the blood vessels in the brain, increasing the risk of vascular dementia.
• Heavy alcohol consumption. Heavy alcohol consumption can cause alcohol-related dementia and can also lead to vascular changes in the brain that in turn increase the risk of developing vascular dementia. Moderate drinking, however, may be protective of the brain, and there is some evidence that red wine is particularly beneficial.
• Education. This is an early life potentially modifiable risk factor linked to late-life dementia risk, either by exerting a direct effect on brain structure by improving vascularization contributing to cognitive reserve, or by shaping healthier behaviors that reduce cardiovascular and cerebrovascular damage.

Incidence/Classification

With the increase in the older adult population in the world, Alzheimer’s disease and related dementia are becoming a global public health challenge. It is predicted that the prevalence of dementia will nearly quadruple in the next 40 years, by which approximately 1 in 45 Americans and 1 in 85 people worldwide will be affected by the disease.

A meta-analysis found that dementia incidence rates declined for clients born in later birth years compared to clients born earlier. This decline was seen in populations from both Western and non-Western countries. On the other hand, Alzheimer’s disease (AD) incidence rates did not decline over time and remained constant in Western countries, while an increasing incidence was actually seen in non-Western countries.

The  5 Most Common Types of Dementia

• Alzheimer’s disease (AD). Alzheimer’s disease, a common neurodegenerative disease that can cause dementia, has a common clinical presentation of slow onset and gradually progressive loss of memory, typically with the inability to learn new information and particularly autobiographical information, such as recent events in one’s life.
• Vascular dementia. Vascular dementia is the second most common type of dementia after AD. This occurs when the brain’s blood supply is compromised by arterial disease, which results in reduced neuronal function and eventually, the death of brain cells. About 10% of dementia cases are linked to stroke or other problems with blood flow to the brain. Diabetes mellitus, hypertension, and hypercholesterolemia are also risk factors.
• Lewy body dementia. Dementia with Lewy bodies is the third most common type of dementia, accounting for 10% of cases. It shares characteristics with AD and Parkinson’s disease. Parkinson’s disease itself can cause cognitive impairment and eventually dementia. Characteristic features of dementia with Lewy bodies include problems with locating the position of objects, visual hallucinations, recurrent falls and marked fluctuations in levels of conscious awareness, and disturbed sleep and/or nightmares.
• Fronto-temporal dementia. This type of dementia most often leads to changes in personality and behavior because of the part of the brain it affects. Frontotemporal dementia is a relatively uncommon type of dementia and covers a range of conditions that affect frontal regions.
• Mixed dementia. More than one type of dementia can co-exist causing mixed dementia. The most common type is mixed Alzheimer’s and vascular dementia, where there are clinical characteristics and brain changes common to both conditions. The disease progression in mixed dementia may be faster than with one kind of dementia.

Treatment

Dementia extends far beyond the four walls of a clinic. This disease causes the client to require constant supervision to complete activities of daily living, whereas the caregivers of these clients bear the physical, psychological, and financial burdens of caregiving. In 2010, 4.2 million adult Americans suffered from dementia, of which 14.7% of adults are above the age of 70. Bearing in mind this big picture, it is important to understand that the therapeutic effects of individual interventions in dementia are modest. However, these modest effects will add up when used inc combination to make significant changes to the quality of life of the clients. Disease-modifying interventions may include:

• Retarding the progression of the disease
• Stopping the progression of the disease
• Reverse the damage already done to the brain
• Ameliorate the cognitive and neuropsychiatric symptoms through pharmacological means

Pathophysiology

Under the DSM-5, dementia is considered a major neurocognitive disorder, in which a deficit in cognitive functioning is acquired rather than developmental. All dementia share common molecular mechanisms responsible for the disease etiology and progression, such as hypoxia and oxidative stress, neuroinflammation, mitochondrial bioenergetics, neurodegeneration, and blood-brain barrier permeability.

The pathogenesis of the vast majority of cases of cognitive impairment and dementia in older adults can be attributed to vascular cognitive impairment and sporadic Alzheimer’s disease. Approximately one-third of the cases of dementia show substantial vascular pathology and vascular cognitive impairment is likely the most common form of cognitive impairment.

Epidemiology of Dementia

The number of people with dementia worldwide is estimated at 44 million and it is projected that it will almost double every 20 years until at least 2050. The number of new cases of dementia each year worldwide is almost 7.7 million. This disease predominantly affects older adults, with global prevalence rates over the age of 60 years ranging from 5% and 7%, increasing exponentially with age; around 20% of people over 85 years have dementia. Dementia is the second largest cause of disability for individuals aged 70 years and older, and the seventh leading cause of death.

However, dementia is not just a disorder in older adults. Earlier data suggested that there were at least 18,000 people younger than 65 years with dementia in the United Kingdom, but this figure could be as high as 40,000.

Dementia imposes an estimated economic cost of approximately $818 billion per year globally – or 1.1% of global gross domestic product. Left unrecognized and undertreated, dementia could represent a significant barrier to social and economic development.

Signs and Symptoms

The term behavioral and psychological symptoms of dementia or neuropsychiatric symptoms describe the heterogenous group of symptoms and signs of disturbed perception, thought content, mood, or behavior that frequently occur in clients with dementia. Throughout the course of the disease, the vast majority of clients will develop one or more of these neuropsychiatric symptoms.

Neuropsychiatric signs and symptoms

• Apathy. This refers to a lack of pleasure, emotion, motivation, or interest, or a state of blunted emotions. Apathy is a very common change seen in dementia and occurs in 48 to 92% of clients. Apathy has three domains: reduced goal-directed behavior, slowness and lack of focus in thinking, and emotional indifference with flat affect.
• Depression. Studies report that major and minor depressive symptoms are seen in approximately one-third to one-half of clients with dementia. Those with a family history of depression are at increased risk for developing major depressive episodes during the course of the disease process.
• Anxiety. Anxiety is another common symptom in clients diagnosed with dementia. This usually occurs alongside depression and seems to limit activities of daily living, resulting in poor quality of life. Anxiety also includes excessive worry that is difficult to control, along with three out of five: restlessness, irritability, muscle tension, fears, and respiratory symptoms.
• Delusions. Delusions of persecution and delusions of misidentification are commissioned in clients with dementia with Lewy bodies.
• Hallucinations. Visual hallucinations are a core feature in defining the characteristics of dementia with Lewy bodies.
• Sexual or social disinhibition. A study found that 6.9% of clients with Alzheimer’s disease exhibited sexually inappropriate behavior such as indecent exposure, obscene sexual language, masturbation, and propositioning others.
• Sleep-wake cycle disturbances. Sleep disturbances in dementia are varied and often several changes occur, including interrupted sleep through the night, prolonged time to fall asleep, and daytime napping. Neurological changes in the brain and reduced daytime activity cause disturbances in the biological control mechanism of the sleep-wake cycle.
• Aggression. Aggression is typically defined as verbal insults, such as shouting, and physical aggression, such as hitting and biting others and throwing objects.
• Agitation. Agitation can manifest as shouting, swearing, verbal threats, pacing, fidgeting, hitting, biting, kicking, and scratching. This is seen in 20 to 45% of clients with mild dementia rising up to 90% in clients with advanced stages of dementia.

Cognitive signs and symptoms

• Amnesia. Amnesia or difficulty in learning new information is the core deficit in Alzheimer’s disease. The inability to remember new information is called ‘anterograde amnesia’. ‘Retrograde amnesia’ is the inability to retrieve previously formed memories and is usually accompanied by loss of episodic memory (memory for personal life events, semantic memory (memory for facts and information about the world), and working memory (remembering a list of words or string of numbers).
• Language deficits. These are apparent even during the early stages of AD and usually include word-finding difficulties. Expressive aphasia is where people cannot find the name of objects or people.
• Apraxia. Apraxia means the inability to perform complex actions despite an intact neuromusculoskeletal system and normal coordination. Common types of apraxia in dementia are:
  • Dressing apraxia. This refers to forgetting the sequence of actions required for dressing and not being able to orientate parts of their body to the garment.
  • Ideational apraxia. The loss of perception of an object’s purpose, like using the flat side of the comb to comb the hair.
  • Ideomotor apraxia. This refers to the breakdown between the idea of an action and its execution, such as when asked to wave goodbye, the client may know the movement but is unable to perform it.
  • Constructional apraxia. The inability to place things in relation to one another, such as drawing a three-dimensional figure.
• Agnosia. This is the inability to interpret information from intact sensory systems, such as touch, taste, sight, smell, and sound. Visual agnosia occurs when the client fails to recognize objects despite seeing them. Prosopagnosia is the inability to recognize faces including one’s own.
• Problems in maintaining attention or poor concentration. Dysexecutive syndrome reflects problems in frontal brain connections causing difficulty with planning, problem-solving, and performing actions in a sequence. The client may also have problems maintaining attention while performing tasks, especially those that require sustained attention.

Prevention

Current epidemiological evidence points to some major strategies that may prevent or delay the onset of dementia. These include:

• Targeting the body to protect the brain. The brain is particularly vulnerable to impairment in blood flow and vascular pathology. This places clients with heart diseases at high risk of developing dementia. Smoking cessation, a healthy and balanced diet, and regular exercise may counteract these changes and delay or prevent the progression of dementia.
• Level of education. The role of education in dementia development must be considered in the context of a life-course model, since early-life education affects a number of closely interconnected factors, including lifestyle and occupation. Passive jobs with lower demand and low controls entail a lack of motivation and mental stimulation and may be detrimental to learning capacity and cognitive performance.
• Leisure and physical activities. Late-life leisure activities involving mental, physical, and social domains have been indicated as crucial contributors to brain protection. The WHO guidelines on risk reduction for cognitive decline and dementia concluded that physical activity should be recommended to adults with normal cognition to reduce the risk of cognitive decline.
• Smoking cessation. The use of tobacco is a major risk factor not only for cancer and CVD but also for dementia. Evidence regarding the harmful effects of smoking on cognition is strong and shows a dose-response effect.
• Decreased alcohol consumption.  Excessive and long-term alcohol consumption has been associated with neurological conditions, such as alcohol dementia and Wernicke-Korsakoff syndrome. Light-to-moderate consumption is associated with a reduced risk of cardiovascular morbidity and cognitive decline and dementia.
• Diet. Diet is an essential factor that can modify the risk of subsequent cognitive impairment and dementia. A regular intake of fish, fruits, vegetables, and potentially moderate alcohol and caffeine consumption has been demonstrated to have a protective effect on cognitive outcomes in older adults.

Medical Management

Clinical trials looking into the effect of lifestyle modifications in dementia are inspired by the fact that 35% of Alzheimer’s disease risk is modifiable. It is clear that, however, even if each intervention completely removes the risk of AD, individual interventions are unlikely to make a significant difference to the overall risk. Therefore, several multimodality intervention trials were designed which combined these interventions in systematic and rigorous ways.

• Diet and exercise. A healthy diet for cognitive purposes may include the Mediterranean and MIND diets (Mediterranean-DASH Intervention for Neurodegenerative Delay). Exercise, 20 minutes three times per week, where the pulse rate reaches 80% of the maximal predicted heart rate, is also recommended unless otherwise contraindicated by other conditions.
• Risk factor modification. Working with the healthcare provider to reduce cardiovascular risk factors is also important. Amongst the target risk factors, hypertension is probably the most important.
• Supplements. The client may use supplements without serious objections from the healthcare provider if they are harmless and cheap. Clinical trials looking into vitamin E, vitamin B12, huperzine, omega-3 fatty acids, Co-Q10, and Gingko Biloba showed no positive influence on dementia and cognitive decline.
• Prevention of delirium. Clients with dementia are at increased risk for delirium, which may be thought of as a neurotoxic state. There are some measures that help prevent delirium, including the scheduled reorientation of the client, consistent daily routine, normal sleep/wake cycle, and socialization.
• Cholinesterase inhibitors. These agents such as donepezil, rivastigmine, and galantamine increase acetylcholine levels and have been approved by the US FDA for the treatment of AD. Cholinesterase inhibitors are also used in vascular cognitive impairment. Clients with Lewy body dementia and Parkinson’s disease dementia respond to cholinesterase inhibitors particularly well.
• Memantine. The N-methyl-D-aspartate (NMDA) receptor antagonist memantine is also approved for moderate to severe dementia. It is thought to be neuroprotective by preventing the pathologic overactivation of the NMDA receptor.
• Cognitive enrichment. It is defined as creating an intellectually stimulating environment for the cognitively affected subject. Clients are oriented and stimulated by activities such as reminiscence therapy, multisensory stimulation, and social activities.
• Cognitive neurorehabilitation. This is conducted by speech therapists and neuropsychologists with the aim of improving functioning. Exercises are geared not toward improving certain cognitive domains but rather focusing on tasks that the subject might undertake during the course of the day.
• Memory clinics. Memory clinics are new, disease-specific management that involves the use of diagnostic techniques, pharmacological, and non-pharmacological treatments for cognitive disorders. Healthcare professionals such as dementia specialists, neuropsychological evaluators, and nurses collaborate to diagnose and treat these clients.

Assessment and Diagnosis

When a client experiences memory loss or other features of dementia, they are usually referred for a specialist assessment. The diagnosis of dementia is a two-stage process: first, to establish if the client has dementia and, second, to determine the likely cause of dementia. The two stages involve obtaining a detailed history from the client and their family, performing mental state and physical examination, and undertaking relevant investigations. Accurate and prompt diagnosis of dementia is imperative for the client and their families so that they could begin making an informed decision that would greatly impact their future.

Cognitive/Memory Assessment

The importance of recognizing dementia has been emphasized by the National Dementia Strategy, which requires that dedicated memory services should be available across the country. The key components of a memory assessment are:

• Early identification and referral of clients with a possible diagnosis of dementia
• Providing high-quality service for dementia assessment, diagnosis, and management.
• Initial assessment involves collecting information about the background of the client, their general functioning, other health problems, a list of medications, and details about their memory complaints alongside any other mood or anxiety complaints. The Glasgow Coma Scale may also be utilized during the initial exam to monitor the client’s level of consciousness.
• Mini-Mental State Examination (MMSE). This comprises questions and tasks that assess memory, language, attention, etc. The total score is out of 30 and a score of 26 or below is considered to be suggestive of dementia.
• Addenbrooke’s Cognitive Examination-Revised (ACE-R). This is a short test battery with more detailed tests on cognitive domains such as memory, attention, language, and spatial orientation. It encompasses the MMSE.
• A comprehensive neurological examination. This is performed for clients with neurological problems which requires extensive assessment. This may be done in specialty settings or by advanced practice nurses. It involves a routine neurological exam, cranial nerve assessment, detailed cerebellar function, and assessment of deep tendon reflexes.

Findings

Findings during the cognitive assessment for a client diagnosed with dementia include the following:

• Multiple cognitive deficits. This refers to problems in more than one cognitive domain, such as memory, language, spatial orientation, organizational skills, etc. Amnesia or memory impairment for learning new information or recalling previously learned information must be one of the core features.
• Functional impairment. There is difficulty in maintaining the ability to perform routine activities at work or at home, or socially, due to cognitive deficits.
• Changes from a previous level. There is a clear decline in this functional impairment when compared to previous abilities with progressive decline.
• Clear consciousness. The client is alert and without any disturbance in consciousness. Altered levels of consciousness can occur in acute confusional states or delirium.

Diagnostic Testing

There may be some potentially reversible causes such as abnormalities in vitamin and calcium levels or hormonal imbalance that can cause memory impairment. To exclude such causes for cognitive impairment the following should be considered:

• Complete blood count. This is done to identify anemia and signs of infection.
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). These are obtained to determine infection or inflammatory responses.
• Thyroid hormone (T4) and thyroid-stimulating hormone (TSH). Hypothyroidism can present with memory difficulties.
• Biochemical screening. This includes urea and creatinine for renal function, electrolytes, liver function tests, and albumin. Sodium disturbances can lead to memory impairment.
• Glucose. This is taken to identify the presence of diabetes mellitus.
• B12 vitamin and folate levels. Deficiencies in these vitamins can produce memory disturbances.
• Neuroimaging. An early step in diagnosing dementia is ruling out non-neurodegenerative neurologic causes of the symptoms, such as brain tumors or stroke. This can be done with either a CT scan or a structural MRI. MRI can also detect specific areas of the brain with degeneration, which is a lot let possible when using a CT scan (Bernstein et al., 2019).

Diagnosis

For diagnosing different types of dementia, there are several international classification systems derived both for research and clinical use. As Alzheimer’s disease (AD) is the most common and most important cause of dementia, it is considered in more detail. In the WHO’s International Classification of Diseases (ICD-10), the following criteria need to be met in order to arrive at a diagnosis of AD:

• Gradual onset and prolonged duration. The symptoms should have occurred gradually with progressive decline with a duration of at least six months.
• There is no evidence of any other neurological or systemic disease that can explain the symptoms of dementia.

Complications

A client in the late stage of dementia is at risk for many complications. Because these clients are mostly bed bound, they are at high risk for certain conditions.

• Infections. The client may develop infections, such as aspiration pneumonia or urinary tract infection. If the client has difficulty swallowing, there is a high risk of aspiration. Food or liquid can enter the airways or the lungs, leading to aspiration pneumonia.
• Malnutrition. Trouble swallowing, eating, and drinking may lead to weight loss, dehydration, and malnutrition. This also increases the client’s risk of infection.
• Mortality. Dementia increases the risk of death from a blood clot in the lung because most of these clients are immobile.

Nursing Management

The key components of nursing management for clients with dementia revolve around the following essential priorities:

1. Safe environment and prevention from injury and harm
2. Independence in assuming basic needs
3. Learning and relearning memories, roles, and abilities
4. Adequate nutrition and health maintenance
5. Behavioral interventions (agitated, restless clients)

Nursing Assessment

Nursing assessment for dementia is an essential step in understanding the unique needs and challenges faced by clients and their families, allowing for the development of personalized care plans that promote quality of life and dignity.

Subjective Cues

• Feeling tired
• Decreased interest  in usual activities or hobbies
• Inability to recall what is read and follow the plot of a television program
• Forced to retire from work
• History of systemic vascular disease, cerebral vascular disease, hypertension, embolic episodes
• Anxiety
• Depression
• Changes in body image or self-esteem
• Changes in taste or appetite
• Denial of hunger or refusal to eat
• Dependence on others to meet basic hygiene needs
• Difficulty in relating to others

Objective Cues

• Hoarding objects
• The belief that misplaced objects are stolen
• Emotional lability
• Apathy
• Lethargy
• Restlessness
• Short attention span
• Irritability
• Catastrophic reactions
• May deny the significance of early changes and symptoms, especially cognitive changes
• Conceals limitations or makes excuses for not being able to perform tasks
• Redirects conversation
• Feelings of delusions or paranoia
• Incontinence
• Hypoglycemic episodes
• Lack of interest or forgetting mealtimes
• Loss of ability to chew
• Weight loss
• Decreased muscle mass
• Disheveled, unkempt appearance
• Body odor
• Inappropriate clothing for the situation or weather conditions
• Inability to reach the bathroom
• Loss of proprioception
• Primitive reflexes may be present
• Disorientation to time then place
• Impaired recent memory
• Difficulty in comprehension
• Impaired communication
• Violence against others
• Ignores safety issues
• Inappropriate behavior and social conduct

Nursing Diagnosis

Nursing diagnoses applicable for a client diagnosed with (disease) include:

• Risk for injury related to the inability to recognize or identify danger in the environment, impaired judgment
• Chronic confusion related to irreversible neuronal degeneration
• Disturbed sensory perception related to altered sensory reception, transmission, and/or integration
• Anxiety related to decreases in functional abilities; public disclosure of disabilities
• Grieving related to client awareness of something “being wrong” with changes in memory; family perception of potential loss of loved one
• Self-care deficit related to cognitive decline, physical limitations
• Risk for imbalanced nutrition: less than body requirements related to impaired judgment and cognition, forgetfulness, regressed habits
• Constipation related to the inability to locate the bathroom or changes in dietary and fluid intake
• Impaired urinary elimination related to lost neurological functioning and muscle tone
• Compromised family coping related to the disruptive behavior of the client
• Ineffective home maintenance related to progressively impaired cognitive functioning
• Risk for caregiver role strain related to illness severity of the client, duration of caregiving required

Nursing Care Planning and Goals

The goals appropriate for the care of a client diagnosed with dementia are:

• The client will recognize potential risks in the environment.
• The client will be free of injury.
• The client will experience a decrease in the level of frustration, especially when participating in daily activities.
• The client will demonstrate an improved or appropriate response to stimuli.
• The client will demonstrate a more appropriate range of feelings and lessened anxiety.
• The client will express concerns openly.
• The client will establish an adequate sleep pattern, with wandering reduced.
• The client will perform self-care activities within the level of their own ability.
• The client will maintain or regain appropriate weight through the ingestion of a balanced diet.
• The client will establish an adequate or appropriate pattern of elimination.
• The client will use outside support systems effectively.
• The client will verbalize the ability to cope adequately with the existing situation.

Nursing Interventions for Dementia

• Involve the client in simple decision-making and provide appraisals for tasks accomplished.
• Plan and provide activities that are routine and scheduled. This way, the client will be accustomed to activities and minimize some disorientation or confusion.
• Plan activities that are realistic and depend on the client’s ability.
• Ensure a safe environment, by providing enough lighting in the room and in the vicinity.
• Provide necessary handrails/ support, place the client’s bed on the lowest level, or/ and always raise the side rails of the bed
• Provide a comfortable, non-restrictive environment. Avoid the use of restraints.
• Let the client wear an identification tag and ensure that the client does not leave the premises (wandering).
• Assist the client in dressing according to the physical environment and individual needs.
• Offer one item of clothing at a time in sequential order while talking to the client through each step of the task.
• Assist the client in their ADLs while at the same time providing some independence depending on the client’s abilities.
• Reorient the client frequently to the environment.
• Provide objects that would make the client recall and relate with, like pictures, significant objects, or even his name by putting his name in his room.
• Put a clock, schedule activities or things he needs to do during the day.
• Avoid frequent changes in arrangements in furniture, etc. to minimize disorientation.
• Remind the client to eat nutritious foods and drink enough fluids/take their medicines.
• Offer small meals and/or snacks of one or two foods around the clock. Provide soft or finger foods.
• Encourage the client to have adequate rest and sleep.
• Speak in a slow-paced manner, considering the client’s limitations or abilities.
• Give simple directions, one at a time, or step-by-step instructions, using short words and simple sentences.
• Provide verbal feedback and positive reinforcement such as a pat on the back or applause. Use touch judiciously and respect the client’s response and personal space.
• Encourage the client to use devices like eyeglasses or hearing aids to improve their sensory inputs.
• For agitation or restlessness, intervene appropriately and avoid situations that would even evoke unexpected behaviors.
• Encourage the client to involve in productive, nonstimulating activities to boost their integrity and esteem.
• Educate the client, family members, and caregiver about the client’s condition and the important things that need to be addressed like his memory loss, impairments in communication, some psychiatric symptoms, and personality changes.
• Create simple, non-competitive activities paced to the client’s abilities.
• Adhere to a regular bedtime schedule and rituals.
• Reduce fluid intake in the evening and encourage the client to use the toilet before sleeping.
• Provide adequate pain management after thorough and routine assessment.

Nursing Evaluation

After the implementation of nursing interventions, the nurse evaluates if the desired goals and outcomes were achieved. The nurse needs to ensure that:

• The client’s environment is safe and there is no injury to the client.
• Inappropriate behavior is limited and socially acceptable responses are exhibited.
• Orientation to reality is maintained and sensory deprivation is prevented.
• Participation of the client in self-care and activities are achieved.
• Coping mechanisms are promoted and practiced.
• Information about the disease process, prognosis, and resources are understood and utilized.

Discharge and Home Care Guidelines

For clients discharged to their homes, monitoring should be performed continually based on the following parameters, which help in the overall management of the disease.

• Determine ongoing treatment needs and appropriate resources.
• Develop a plan of care with family to meet the client’s and significant other’s individual needs.
• Provide appropriate referrals, such as Meals on Wheels, adult day care, home care agency, respite care, etc.)
• Stress the importance of keeping vision/hearing aids in good repair and the necessity of periodic evaluation to identify changing client needs.
• Ensure appropriate and adequate pain management is provided for the client.
• Review the client’s medication regimen.
• Discuss the situation with the family and involve them in planning to meet identified needs.
• Assist client and family members to establish compensation strategies to improve functional lifestyle and safety, such as menu planning with a shopping list, timely completion of tasks on a daily planner, or checklists at the front door.
• Assist the client to deal with functional limitations and identify resources to meet individual needs, maximizing independence.

Nursing Documentation

The focus of documentation on a client diagnosed with dementia should include the following:

• Individual findings, including current level of function and rate of anticipated changes
• Plan of care and who is involved in planning
• Response to interventions and actions performed
• attainment/progress toward desired outcomes
• Modifications to plan of care
• Long-term needs or referrals and who is responsible for actions to be taken
• Available resources and specific referrals made

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