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Characterized by emotion DEPRESSION It is the most common affective or mood disorder of old age and is often responsive to Identifying the nature of cause treatment. Its classification and diagnosis vary according to the number, severity, and duration of symptoms. Depression disrupts quality of life, increases the risk of suicide, and becomes self-perpetuating. Continuous It may also be an early sign of a chronic illness or the result of physical illness.

Signs of depression include: Feelings of sadness Fatigue Diminished memory and concentration Feelings of guilt or worthlessness Sleep disturbances Appetite disturbances with excessive weight loss or gain Restlessness Impaired attention span Suicidal ideation Although depression among the elderly is widespread, it is often undiagnosed and untreated. Attentive clinical evaluation is essential.
learning and reasoning

Geriatric depression and symptoms of dementia often overlap, so cognitive impairment may be a result of depression rather than dementia. When depression and medical illnesses coexist, as they often do, neglect of the depression can retard physical recovery. Assessing the patients mental status, including assessing for depression, is vital and must not be overlooked. Depressive illness in late life should be vigorously treated with antidepressants. Psychosocial approaches have also been found to be effective. Selective serotonin reuptake inhibitors (SSRI) are clinically useful and exhibit rapid action with a low occurrence of adverse effects. It may take 4 to 6 weeks for symptoms to recede, so the nurse/caregiver should offer explanations and encouragement during this period. Alcohol abuse related to depression is significant in the elderly population. Alcohol-related problems in older people often remain hidden, since many older adults deny their habit when questioned.
Alcohol is a depressant

Alcohol abuse is especially dangerous in the older person because of changes in renal and liver function as well as the probability of side effects in interactions with prescriptive medications. DELIRIUM Delirium, often called acute confusional state, begins with confusion and progresses to disorientation. The patient may experience an altered level of consciousness ranging from stupor to excessive activity. CHARACTERISTICS: Thinking is disorganized Attention span is short Hallucinations Delusions Fear Anxiety Paranoia
feeling of distress and disbelief

Because of the acute and unexpected onset of symptoms and the unknown underlying cause, delirium is a medical emergency. Delirium occur secondary to a number of causes: Physical illness Medication or alcohol toxicity Dehydration Fecal impaction Malnutrition Infection Head trauma Lack of environmental cues Sensory deprivation or overload Older adults are particularly vulnerable to acute confusion because of their decreased biologic reserve and the large number of medications that many take. The nurse must recognize the grave implications of the acute symptoms and report them immediately. If the delirium goes unrecognized and the underlying cause is not treated, permanent, irreversible brain damage or death can follow. Delirium is sometimes mistaken for dementia. Therapeutic interventions vary, depending on the reason for the symptoms. Because medication interactions and toxicity are often implicated, nonessential medications should be stopped. CAREGIVING RESPONSIBILITIES: Nutritional and fluid intake should be supervised and monitored The environment should be quiet and calm. To increase orientation and provide familiar environmental cues, we encourage family members or friends to touch and talk to the patient. It is important to question the family carefully about the patients prior cognitive state. Ongoing mental status assessments using this baseline are helpful in evaluating responses to treatment and to the hospital or extended care facility admission. THE DEMENTIAS: MULTI-INFARCT DEMENTIA AND ALZHEIMERS DISEASE Dementia reportedly affects 3% to 11% of community-residing adults older than 65 years of age and 20% to 50% of community residing adults older than age 85. Most of those suffering from dementia who are in the over-85 age group reside in institutional settings. In order for a diagnosis of dementia to be made, at least two domains of altered function must exist memory and at least one of the following: Language Becoming aware inability to discern Perception of something via spaces like the senses Visuospatial function building legos and Calculation the likes Judgment Abstraction Problem-solving Symptoms are usually subtle in onset and often progress slowly until they are obvious and devastating. The changes characteristic of dementia fall into three general categories: Cognitive Functional Behavioral

CAUSES OF DEMENTIA CAN BE CLASSIFIED INTO TWO: A. Reversible causes of dementia alcohol abuse medication use (polypharmacy) psychiatric disorders normal-pressure hydrocephalus B. The three most common nonreversible dementias are: Alzheimers disease Multi-infarct dementia Mixed Alzheimers and multi-infarct dementia Alzheimers disease accounts for more than 60% of all dementias, and multi-infarct dementia (vascular dementia) accounts for another 5% to 20%. Other non-Alzheimers dementias include Parkinsons disease Inability to use or understand language AIDS-related dementia Picks disease loss of intellectual ability and transitory aphasia These remaining dementias account for fewer than 15% of cases and are relatively uncommon. Dementia is characterized by an uneven, downward decline in mental function. Multi-infarct, or vascular dementia, has the following defining characteristics: There must be evidence of dementia. There must be evidence of cerebrovascular disease (by history, clinical examination, or brain imaging). The two disorders must be reasonably related. Alzheimers disease is a progressive, irreversible, degenerative neurologic disease that begins insidiously and is characterized by gradual losses of cognitive function and disturbances in behavior and affect. Alzheimers disease is not found exclusively in the elderly; in 1% to 10% of cases, its onset occurs in middle age. TWO ESTABLISHED RISK FACTORS FOR ALZHEIMERS DISEASE A family history of Alzheimers disease The presence of Down syndrome Amyloid - a waxy translucent complex protein resembling
starch that results from degeneration of tissue

Pathophysiology Specific neuropathologic and biochemical changes are found in patients with Alzheimers disease. These include neurofibrillary tangles (a tangled mass of nonfunctioning neurons) and senile or neuritic plaques (deposits of amyloid protein, part of a larger protein, APP) in the brain. Clinical Manifestations EARLY STAGES OF ALZHEIMERS DISEASE Forgetfulness and subtle memory loss Small difficulties in work or social activities but has adequate cognitive function to hide the loss Can function independently Depression may occur at this time In FURTHER PROGRESSION OF THE DISEASE, the deficits can no longer be concealed. Forgetfulness is manifested in many daily actions Loses their ability to recognize familiar faces, and objects May get lost in a familiar environment Repeat the same stories because they forget that they have already told it Conversation becomes difficult, and there are word-finding difficulties The ability to formulate concepts and think abstractly disappears

The patient is often unable to recognize the consequences of his or her actions and will therefore exhibit impulsive behavior. The patient has difficulty with everyday activities, such as operating simple appliances and handling money. Personality changes are also usually evident. The patient may become depressed, suspicious, paranoid, hostile, and even combative. Trying to reason with the person and using reality orientation only increase the patients anxiety without increasing function. PROGRESSION OF THE DISEASE intensifies the symptoms: Speaking skills deteriorate to nonsense syllables Agitation and physical activity increase The patient may wander at night Assistance is needed for most ADLs, including eating and toileting, since dysphagia occurs and Incontinence develops. TERMINAL STAGE The patient is usually immobile and requires total care May last for months or years The patient may or may not recognize family or caretakers. Death occurs as a result of complications such as pneumonia, malnutrition, or dehydration 10 WARNING SIGNS OF ALZHEIMERS DISEASE A person with several of these symptoms should see a physician for a thorough evaluation: 1. Memory loss that affects job skills 2. Difficulty performing familiar tasks 3. Problems with language, as in word-find problems or inappropriate word substitutions 4. Disorientation about time and place 5. Poor or decreased judgment 6. Problems with abstract thinking 7. Misplacing things 8. Changes in mood or behavior 9. Changes in personality 10. Loss of initiative Assessment and Diagnostic Findings Depression can closely mimic early-stage Alzheimers disease and coexists in many patients. Probable Alzheimers disease is determined when physicians and psychiatrists rule out all other disorders that might produce similar symptoms. A diagnosis of possible Alzheimers disease is made when Alzheimers disease is considered the primary reason for the symptoms but is complicated with the presence of another disorder that might confuse the general progression of the disease A diagnosis of probable Alzheimers disease is made when the medical history, physical examination, and laboratory tests have excluded all known causes of other dementias. The diagnosis can be confirmed only by cerebral biopsy. Nursing Management Interventions are aimed at maintaining the patients: Physical safety Reducing anxiety and agitation Improving communication Promoting independence in self-care activities Providing for the patients needs for socialization Self-esteem and intimacy Maintaining adequate nutrition

Managing sleep pattern disturbances Supporting and educating family caregivers Research has demonstrated that when the nurse can provide such support, older adults are able to maintain higher levels of perceived and actual health. SUPPORTING COGNITIVE FUNCTION As the patients cognitive ability declines, we should provide a calm, predictable environment that helps the person interpret his or her surroundings and activities. Environmental stimuli are limited, and a regular routine is followed. A quiet, pleasant manner of speaking, clear and simple explanations, and use of memory aids and cues help to minimize confusion and disorientation and give the patient a sense of security. Prominently displayed clocks and calendars may enhance orientation to time. Color coding the doorway may help the patient who has difficulty locating his or her room. Active participation may help the patient to maintain cognitive, functional, and social interaction abilities for a longer period. Physical activity and communication have also been demonstrated to slow some of the cognitive decline of Alzheimers disease. PROMOTING PHYSICAL SAFETY A safe environment allows the patient to move about as freely as possible and relieves the family of constant worry about safety. To prevent falls and other injuries, all obvious hazards are removed. Nightlights are helpful. The patients intake of medications and food is monitored. Smoking is allowed only with supervision. A hazard-free environment allows the patient maximum independence and a sense of autonomy. Because of a short attention span and forgetfulness, wandering behavior can often be reduced by gently persuading or distracting the patient. Restraints are avoided because they may increase agitation. Outside the home, all activities must be supervised to protect the patient, and the patient should wear an identification bracelet or neck chain in case he or she becomes separated from the caregiver.