I.

INTRODUCTION
The term cognition describes ones ability to learn, think, and process
information. These functions must be intact in order for a normal life to be
possible. However, impairment of these functions can result in difficulties in
coping with both complex and daily activities. With this, cognitive disorders,
category of mental health disorders that primarily affecting learning, memory,
perception, and problem solving, can somehow develop throughout ones life.
These disorders include delirium, dementia, and amnesia.
Cognitive impairment and dementia are increasing globally and are
predicted to increase proportionately more in developing regions. Projections
indicate that by 2050 the number of individuals older than 60 years will be
approximately 2 billion and will account for 22% of the worlds population.
Four fifths of the people older than 60 years will be living in developing
countries in Africa, Asia or Latin America. It is estimated that 35.6 million
people are currently living with dementia worldwide and that the number will
nearly double every 20 years, reaching 115.4 million in 2050, with the majority
living in developing countries. Of the total number of people with dementia
worldwide, 57.7% lived in developing countries in 2010 and a proportionate
increase to 70.5% by 2050 is anticipated.
Cognitive disorders are typically diagnosed following physical and
neurological examinations. Imaging tests, blood tests, liver function tests and
thyroid tests may also be performed. Treatment options differ depending on
which condition is present. Though delirium can usually be treated effectively
by addressing the underlying condition, the prognosis may be less optimistic
for patients with dementia or amnesia . Thus, these have an enormous
societal impact because special educational resources are required, and
independent living often cannot be achieved. Learning problems may lead to
behavioral disorders in the home and community.

I.

Cognitive Disorders

Types

Etiology

Clinical Manifestations

Three major causes:

Impaired Judgment

Delirium due to a General

Central Nervous System Diseases

Affect of mood fluctuates

Medical Condition

(eg, Epilepsy, Meningitis,

Impaired memory of

Encephalitis)

Systemic Illnesses

insufficiency)

Drug intoxication or withdrawal

from pharmacologic or toxic

physiologic consequence

of a general medical

Dysnomia-inability to
name objects

agents
Other causes:

disturbance is a direct

Disorientation to person
and place

Dysgraphia-impaired

condition

Speech is incoherent,

Endocrine/Metabolic disorders

Deficiency diseases

Electrolyte imbalances

misinterpretations,

Postoperative states

illusions, hallucinations

Traumatic Injury to the head or

sparse, or fluent.

Perceptual disturbances

Thought processes
appear confused

body

Agitation, Restlessness,

Focal lesions of the right

parietal lobe and occipital

ability to write

When findings indicate

that the cognitive

recent events

(eg, Heart failure, Pulmonary

Delirium

Diagnostic Characteristics

lobe
Substance-Induced Delirium

Occur within minutes to

hours after taking high
doses of certain drugs

Delirium resolves as the

substance is discontinued
or eliminated from the
body
2

Wandering, Disturbed

Anesthetics, analgesics,

sleep-wake cycle

antihistamines,

Asterixis- peculiar

anticonvulsants, anti-

flapping of

asthmatics,

hyperextended hands

antiparkinsonism drugs,

Hypoactive symptoms-

corticosteroids, muscle

lethargy, reduced

relaxants are reported to

psychomotor activity

cause delirium
Delirium due to Multiple
Etiologies

Diagnosed in situations
where delirium has more
than one etiology

Delirium Not Otherwise

Specified

Delirium that does not

meet criteria for any
specific type of delirium

Insufficient evidence to
establish a specific
etiology

Types

Etiology

Clinical Manifestations

The cause of dementia varies

Mild

and often no diagnosis can be

made until completion of a

postmortem examination.

Metabolic activity is decreased

Dementia

in the brains of clients with

decrease metabolic activity or

if decrease metabolic activity

results in dementia.
A genetic component has been
identified for some dementias
such as Huntingtons disease
and Alzheimers disease.
Other causes of dementia are

Loss of Memory

Hallmark:
Forgetfulness

Initial Stage:

Difficulty finding

Recent memory loss

Frequently loses

Later Stage:

object

Remote memory loss

Anxiety about the

Deterioration of Language

Function: (Aphasia)
Loss of Ability to think

losses

Occupational and
social setting are less
enjoyable

Moderate

Confusion is apparent

Progressive memory

abstractly and to plan,

initiate, sequence, monitor,
or stop complex behavior.

loss

related to infections such as

Human Immunodeficiency

words

dementia; it is not known

whether dementia causes

Diagnostic Characteristics

Person loses the

Virus (HIV) infection or

ability to live

Creutzfeldt- Jakob disease.

It can also be due to direct

independently

Requires assistance

pathophysiologic consequence
4

of head trauma. Other

because of

underlying disease condition

disorientation to time

can also lead to dementia such

and loss of

as Vascular Dementia, Picks

information

Disease and Parkinsons

Disease.

Severe

Personality and
emotional changes
occur

Person may be
delusional

Might wander at
night

Forget the family

member

Requires assistance
in activities of daily
living

Most live in nursing

facilities during this
stage unless
extraordinary
community support is
5

Types

Etiology

available.
Clinical Manifestations

Diagnostic Characteristics

Caused by structural or

Loss of memory

impairment: memory

chemical damage to parts of

Disorientation with

significantly decreased

time and space

from usual level;

Lack of insight to their

considered transient if

loss of memory

impairment lasting for 1

Difficulty in learning

month or less, considered

the brain.

Amnestic
Disorder

Evidence of memory

chronic if impairment

or recalling

occurring longer than 1

information

Awareness of their
loss of memory but

month.

Demonstration of
significant problems with

unable to understand

social or occupational

why

functioning.

History, physical
examination and
laboratory findings
indicative of medical
condition underlying the
memory impairment.
6

II.

Management

PSYCHOTHERAPIES
DEMENTIA

Therapeutic Milieu is used most often with patients who exhibit behaviours that
are difficult to manage. The therapies consist of changing environmental factors
thought to affect the patients and to reduce the patients' behavioural problems

Emotion-oriented therapies include options like psychotherapy. They are often

used to address issues of memory loss and to improve mood and behaviour.

Cognitive therapy include reality orientation, cognitive retraining and skills

focusing on cognitive deficits. This type of treatment provides some
improvements, but they are generally short-term.

Stimulation-oriented therapy includes therapies related to pleasurable

activities, such as art, music or exercise. Some data demonstrates its relative
effectiveness in reducing behavioural problems.
o Art therapy
o Music therapy

DELIRIUM

Therapeutic Milieu - The environment should be stable, quiet, and well-lighted.

Cognitive Therapy - Reorientation techniques or memory cues such as a

calendar, clocks, and family photos may be helpful.

AMNESTIC DISORDERS

Cognitive therapy include reality orientation, cognitive retraining and skills

focusing on cognitive deficits. This type of treatment provides some
improvements, but they are generally short-term.

Psychonalysis brings to the surface repressed memories.

 PHARMACOLOGIC
A. Delirium
Haloperidol (Haldol)
Classification

Antipsychotic

To decrease agitation

Indication

Action
Haloperidol interferes with the effects of neurotransmitters in the brain which are the
chemical messengers that nerves manufacture and release to communicate with one
another. Haloperidol blocks receptors for the neurotransmitters (specifically the
dopamine and serotonin type 2 receptors) on the nerves. As a result, the nerves are not
"activated" by the neurotransmitters released by other nerves.

Adverse Effects

extrapyramidal effects (sudden, often jerky, involuntary motions of the head,

neck, arms, body, or eyes)

dizziness

hyperactivity

tiredness

nausea

seizure

Nursing Considerations
1. Take this medication by mouth with or without food, or as directed by the doctor.
2. Use this medication regularly in order to get the most benefit from it. To help you
remember, use it at the same time(s) each day.
3. Do not stop taking this medication without consulting your doctor.
4. Tell the doctor promptly if any of these side effects occur: muscle
spasm/stiffness, shaking (tremor), restlessness, mask-like facial expression,
drooling.

B. Dementia
Donepezil (Aricept)
Classification

Cholinesterase inhibitor

Slow the progress of dementia

improve memory, awareness, and the ability to function

Indication

Action
Inhibits acetylcholinesterase, an enzyme responsible for the destruction of one
neurotransmitter, acetylcholine. This leads to increased concentrations of acetylcholine
in the brain.
Adverse effects
The most common side effects associated with donepezil are:

headache

generalized pain

fatigue
10

dizziness

nausea

vomiting

diarrhea

loss of appetite

weight loss

muscle cramping

joint pain

insomnia

Increased frequency of urination

Nursing Considerations
1. Taken once daily at night prior to retiring. Its absorption is not affected by food so
that it may be taken with or without food.
2. If there is a missed dose, use it as soon as remembered. If it is near the time of
the next dose, skip the missed dose and resume to usual dosing schedule. Do
not double the dose to catch up.
Selective Serotonin Reuptake Inhibitor (SSRI)
SSRIs approved by the Food and Drug Administration (FDA) to treat depression, with
their generic names followed by brand names in parentheses, include:

Citalopram (Celexa)

Escitalopram (Lexapro)

11

Fluoxetine (Prozac)

Paroxetine (Paxil, Pexeva)

Sertraline (Zoloft)

Classification

Antidepressant

Indication

To ease symptoms of moderate to severe depression

Action
SSRIs ease depression by affecting naturally occurring chemical messengers
(neurotransmitters), which are used to communicate between brain cells. SSRIs block
the reabsorption (reuptake) of the neurotransmitter serotonin in the brain. Changing the
balance of serotonin seems to help brain cells send and receive chemical messages,
which in turn boosts mood.
Adverse Effects
Side effects of SSRIs may include, among others:

Nausea

Nervousness, agitation or restlessness

Dizziness

Reduced sexual desire or difficulty reaching orgasm or inability to maintain an

erection (erectile dysfunction)
12

Drowsiness

Insomnia

Weight gain or loss

Headache

Dry mouth

Vomiting

Nursing Considerations
1. Take the medication with food to reduce risk of nausea/vomiting.
2. It is best to take it at bedtime since it could cause sedation.
3. Inhibit intake of anitcoagulants or pain relievers because it could increase the risk
for bleeding when combined with SSRIs.
4. Do not stop medication abruptly because it can cause withdrawal-like symptoms.

13

NURSING CARE PLAN #1

CUES

NURSING
DIAGNOSIS

OBJECTIVES

Subjective

Disturbed

Short term:

Cues:

thought

After 30

a. Ideas of

processes

minutes of

reference
b. Hallucination

related to

nursing

hallucinations

interventions,

s
c. Delusions
Objective Cues:
a. Disorientation
to the person,
place, and
time
b. Memory
deficit,
altered
attention
span, and
decreased
ability to
grasp ideas

INTERVENTIONS

RATIONALE

Short term:
1. Meet with patient each

1. Short, consistent

day for 30 minutes to

meetings help

establish trust and

decrease anxiety

support.

and establish

and delusions the patient will

trust.

be able to:

reality
based
ideas.
b. be free from
injury.
c. respond
decreased
anxiety
level.
d. verbalize
recognition

After 30 minutes
of nursing
interventions,
the patient was
able to:
a. verbalize

a. verbalize
logical and

EVALUATION

2. Interrupts
2. Observe for signs of
hallucinations. When
these symptoms are
noted, engage the
patient in here-andnow, reality-oriented
conversation or involve
the patient in here-andnow activity.
3. Communicate

patterns of
hallucinations.

logical and
reality based
ideas.
b. be free from
injury.
c. respond
decreased
anxiety level.
d. verbalize
recognition
of delusional
thoughts if
they persist.
14

c. Impaired

of

ability to

delusional

make

thoughts if

decisions and

they persist.

problem
solve
d. Disoriented

Long term:

acceptance to the

3. Provide

patient to encourage

information on

the sharing of the

the content of

content of the

the hallucination

hallucinations.

so early

After 3 hours of

intervention can

thought

nursing

be initiated when

sequencing

interventions,

content suggests

the patient will

harm to the

be able to:

client or others.

a. express

ideas with
the absence
of
delusions,
flight of
ideas with
the absence
of
delusions,

After 3 hours of
nursing
interventions,
the patient will
be able to:
a. express
logical, goal
directed
ideas with

logical, goal
directed

Long term:

the absence
4. If hallucinations place

4. Patient and staff

of delusions,

the patient at risk for

safety are of

flight of

self-harm or harm to

primary

ideas with

others, place the

importance.

the absence

patient on one-to-one

of delusions,

observation or in

fight or flight

seclusion.
5. Teach patient to control
hallucinations by:

of ideas
b. be free from
delusions or
demonstrate
15

fight or flight
of ideas
b. be free from
delusions or

the ability to
a. Checking ideas
out with trusted

patients sense

others.

of control, and

demonstrate
the ability to
function
without
responding
to persistent
delusional
thoughts

5. Promotes the

enhances selfb. Practicing

thought
stopping by
singing to self,

esteem. Provide
s control of

function
without
responding
to persistent
delusional
thoughts

auditory
alterations.

telling the
voices to go
away.
c. Telling the
voices to go
away, using
headphones to
listen to music,
watching tv, or
wearing ear
plug in one ear.
6. Refer the patient to
appropriate support
16

systems in
the community.

6. Establishes
7. Be sincere and honest

continuity of

when communicating

responses and

with the client. Avoid

support for the

vague or evasive

patient after

remarks

discharge.

7. Delusional
clients are
extremely
sensitive about
others and can
recognize
insincerity.
17

Evasive
comments or
hesitation
reinforces
mistrust and
delusions.

NURSING CARE PLAN #2

CUES

NURSING

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUAT
18

DIAGNOSIS
Subjective Cues:

Ineffective role

Short term:

a. reported change

performance

in sensory acuity
b. sensory
distortions
Objective Cues:
a. measured
change in
sensory acuity
b. change in
unusual
response to
stimuli
c. change in
behavior pattern;
restlessness;
irritability
d. change in

1. To identify medication

Short term

After 30 minutes of

with effects or rug

After 30 minu

related to loss of

nursing intervention,

interactions that may

nursing interv

previous

the patient will be

cause or exacerbate

the patient wa

capabilities

able to:

sensory or perceptual

to:

a. regain or
maintain usual

2. Determine response to
painful stimuli.

cognition.
b. Recognize and
correct or
compensate for
sensory
impairments.
c. Verbalize
awareness of
sensory needs
and presence of
overload and/or

abilities; poor

deprivation.

3. Encourage use of
listening devices (eg.
Hearing aid, audiovisual amplifier, closed-

a. regain or

maintain u
level of

appropriate to

cognition.
b. Recognize

stimulus, immediate,
or delayed.
3. To assist in managing
auditory impairment.

awarenes

physically or

offer feedback.

compensa

impairmen
c. Verbalize

interpreter).
4. Avoid isolation of client,
emotionally.
5. Interpret stimuli and

correct or
sensory

caption TV, signing

6. Minimize discussion of
Long term:

problems.
2. To note whether
response is

level of

problem-solving
concentration
e. disorientation;

1. Monitor drug regimen.

4. To prevent sensory

sensory n

deprivation/ limit

and prese

confusion.
5. To assist client to

overload a

deprivatio

separate reality from

fantasy or altered

Long term:
19

hallucinations;

After 3 hours of

illusions; bizarre

nursing intervention,

thinking
f. impaired
communication
g. motor
incoordination,
altered sense of
balance/falls

the patient will be

able to:
a. Identify and
modify external
factors that
contribute to

negatives within clients

hearing.
7. Speak to visually

perception.
6. Client may
believe references

unresponsive client

are to himself or

stimulation as care is
given.

alterations in

nursing interv

misinterpret and

impaired or
during care.
8. Provide tactile

After 3 hours

the patient wa
to:

a. Identify an

herself.
7. To provide auditory

modify ext

factors tha

stimulation and

contribute

prevent startle reflex.

8. Touching is an

alterations

sensory or

important part of

sensory or

perceptual

caring and a deep

perceptual

abilities.
b. Use resources

psychological need

effectively and
appropriately.
c. Be free of injury.

9. Position doors and

furniture so they are out
of travel path for client
with impaired vision, or
strategically place items
or grab bars.

abilities.
b. Use resou

communicating

effectively

presence and

appropriate
c. Be free of

connection with
another human being.
9. To aid in maintaining
balance.
10. To enhance balance.

10. Ambulate with

assistance and devices.

20

NURSING CARE PLAN #3

CUES

NURSING
DIAGNOSIS

Subjective Cues:

OBJECTIVES

Risk for Injury After 30 minutes

voilence
e. Hallucinations
f. Delusions

related to

of nursing

cognitive

interventions,

impairment

the patient will

and

be able to:

wandering

a. Spared from

behavior

injury

Unable to
recognize /
identify
hazards in the

b. Control

environment.

activities that
can prevent

Disorientatio
n, confusion,

RATIONALE

Short term:

d. Ideas of self

Objective Cues:

INTERVENTIONS

injuries.

EVALUATION

Short term:
1.

Assess the

1.

Impairment of

degree of

visual

impaired ability of

perception

competence

increase the

emergence of

risk of falling.

impulsive

Identify

behavior and a

potential risks in

decrease in

the environment

visual perception.

and heighten
awareness so
that caregivers
more aware of

After 30 minutes
of nursing
interventions,
the patient will
be able to:
a. Spared from
injury
b. Control
activities that
can prevent
injuries.

21

c. Identifying
impaired
decision
making.

factors that

c. Identifying
2.

Help the

the danger.

people closest to

could cause

identify the risk of

injury.

2.

cognitive and

hazards that may

Weakness,
the muscles

disorders are

Long term:
After 3 hours of

coordinated,

nursing

the presence

interventions,

of seizure

the patient will

activity.

be able to:

beginning to
experience the
trauma as a
result of the
inability to take
responsibility for

c. 1. Mention

basic security

the simple

capabilities, or

language of

evaluating a

the factors
that cause

3.

minimize sources

2. Using the

of hazards in the

proper way

environment

to prevent
injury
3.

particular

Eliminate /

injury

could cause
injury.

perceptual

arise.

are not

An impaired

factors that

situation.
3.

Maintain
security by
avoiding a
confrontation

Long term:
After 3 hours of
nursing
interventions,
the patient will
be able to:
d. 1. Mention
the simple
language of
the factors
that cause
injury
2. Using the
proper way
to prevent
injury
3. Controlling
22

Controlling

the activity
that could

the activity

improve the

according to
ability

according to
ability

behavior /
4.

Divert attention

increase the

to a client when

risk for injury.

agitated or
dangerous

4.

Manipulate

behaviors like

the activity to

getting out of bed

facilitate control

by climbing the

of behaviors.

fence bed.

23

III.

Journal Readings

DELIRIUM
Improving patient care through the prism of psychology: Application of Maslow's
hierarchy to sedation, delirium, and early mobility in the intensive care unit
Jackson, James C ; Santoro, Michael J; Ely, Taylor M; Boehm, Leanne; Kiehl, Amy L;
et al.Journal of Critical Care 29.3 (Jun 2014): 438-44.

Introduction
In the intensive care unit (ICU), physicians and nurses work tirelessly to support
and enhance healing of patients' bodies to decrease death rates.
Advances in critical care have led to greater survival from life-threatening
illnesses. In addition, although the overall number of hospital beds remains stable, the
percentage of ICU beds is rising [1,2] . Survivorship from the acute respiratory distress
syndrome and mechanical ventilation has doubled from a mere 40% in 1990 up to
80% in 2010 [3-6] . Although ICU teams provide a myriad of life support techniques to our
sickest ICU patients, an ill-adopted practice evolved over the past 25 years of keeping
patients in a state of iatrogenic coma and immobilization rather than allowing them to
remain conscious and aware of their physical struggles in the ICU. Although this
practice was and still is needed transiently for an important minority of patients with the
worst hypoxemic respiratory failure on mechanical ventilation, this custom is not
necessary for most patients and in fact is setting them up for long-term disabilities now
recognized as the unfortunate cognitive, psychiatric, and physical legacies of
survivorship[7-10] . Although the basic, physical needs of patients are being met and they
are able to leave the hospital after their illness, their quality of life and emotional needs
are suffering greatly in the months and years afterward as they encounter long-term
cognitive impairment [11-13] , ICU-acquired weakness [14-18] , and psychiatric disorders
such as depression and posttraumatic stress disorder [12,19-21] .
Maslow's hierarchy provides helpful lens
Our goal in this article is to refresh the way we look at patients in the ICU and
how they survive critical illness, so that we essentially "reboot" the way we think about
and organize patients' care during and after their hospitalization. Physical recovery and
mere survival from the ICU can no longer be our measures of success, but overall
quality of life for patients, psychologically and physically, once out of the ICU, must be
24

our new focus. One model from psychology by Abraham Maslow that has been taught
and studied for 60 years--Maslow's hierarchy of needs [8,22] --provides a framework by
which to take a second look at our ICU customs and, perhaps, improve the quality of
survival for our patients. Maslow's basic construct proposes that there are 5 levels of
needs (Fig. 1 A) that must to be satisfied to promote healthy well-being. The 2 bottom
levels of his hierarchy address physiologic deficits and associated safety issues, such
as security and stability, which play an important role in the immediate survival of an
individual. The 3 higher levels address psychologic needs that include feelings of
belonging or love, self-esteem, and self-actualization (ie, creativity or fulfillment of
potential) [23,24] . For our purposes in looking at ICU care, once the most basic and
physiologic needs are met, patients and their families can proceed to concerns
regarding psychologic and higher order needs. Survivorship physically is no longer a
satisfactory goal but rather brain function, happiness, and physical abilities of the patient
should all be considered important needs that can be immediately addressed and
incorporated into ICU care [7-10] .
Physiologic needs and safety, the basic (ie, bottom) levels of Maslow's hierarchy,
are often the focus of patientcare guidelines in current literature. In 2013, the Society of
Critical Care Medicine developed the pain, agitation, and delirium [25] evidence-based
guidelines to help direct improvements in patient care, whereas also liberating patients
from chemical and physical restraints. However, despite myriads of data over the past
decade speaking to the dangers of over sedation and immobilization, data show that of
13 categories of clinical guidelines, those related to sedation are last in terms of
adoption and compliance [26] . For example, although delivering mechanical
ventilation in a culture of minimal sedation for awake patients [27-31] , it is still very
common to find ICU studies documenting ongoing high doses of deep sedation and/or
high doses of benzodiazepine use in which not even the trial protocols break that
behavior [32-34] . What often happens is that sedation is stopped in the morning for a brief
period and then resumed later that day or during the night when the patient begins to
wake up and is delirious [34] . The physician on-call or the nurses on duty either will not,
cannot, or simply do not spend time dealing with an awake patient [34,35] or perhaps,
operate under the belief that people should not be awake while receiving mechanical
ventilation. Although it is of course difficult to change the habits and culture of how we
handle the patients in this example, more specific focus on Maslow's second stage,
safety, can help the health care team focus on how it is safer to let the brain resume
normal activity as soon as possible in critical illness and that early mobilization of the
patient's brain and body better targets the patient's health needs. Sadly, despite
numerous studies and reviews covering the scientific evidence for these innovations,
the status quo often remains the same in too many ICUs.

25

Barriers to change and understanding Maslow's hierarchy via other disciplines

Gawande [36] wrote an article in the July 29, 2013 issue of The New Yorker
entitled "Slow ideas: some innovations spread fast. How do you speed the ones that
don't?" He noted that slow adoption of evidence (similar to what we have seen in the
ICU setting) is especially problematic for issues that are invisible and for those that tend
to benefit one party but may seem disadvantageous to the other party. In the ICU, a
problem such as hypoactive "quiet" delirium is often overlooked (ie, it is invisible) by
critical care teams as it requires proactive steps for discovery and then subsequent
monitoring and management of the delirium, all of which may appear disadvantageous
and more work for the physicians and nurses. Yet, as reviewed in recent
publications [25,37] , researchers have identified acute cognitive dysfunction or delirium as
an independent predictor of poor outcomes including duration of mechanical ventilation,
discharge disposition, functional and cognitive decline, and mortality rates. By adopting
better practices in the ICU, health care professionals would not only be attending to the
physiologic and safety needs of the patient, they would also be establishing the
foundation upon which the other needs (ie, love and belonging, esteem, and selfactualization) could be routinely addressed.
The generalized principle of Maslow's hierarchy of needs allows for its
application in a variety of settings, as has been demonstrated in other scientific
fields [22] and
health care settings [38-43] to
help
foster
a
culture
of
change. Nursing continues to be a leading field that has adopted Maslow's
ideas in determining care plans and acknowledging patient concerns [43] . Standard
hospice and palliative care medicine have also followed similar trajectories by
emphasizing patient pain, symptom, and disease management. For example, Zalenski
and Raspa [44] applied Maslow's schema to hospice care and were able to treat
distressing symptoms such as pain and dyspnea, physical and emotional fears as well
as provide acceptance and respect in the face of a terminal illness. Emergency
medicine [42] , traumatic brain injury [45] , fall prevention [38] , hemodialysis [39] , cognitive
rehabilitation [40] , and severe intellectual disability [41] have all been influenced by
applications of Maslow's schema in the management of patient care and survivorship.
Although the validation of Maslow's hierarchy of needs has not been conducted with
geriatric patients, Majercsik [46] observed that geriatric patients rated self-actualization as
their primary objective, and physiologic pain was rated least important. Ina ddition, there
is a long history in the field of psychology effectively informing key aspects of
health care through theories such as Prochaska's transtheoretical model of behavior
change and Kubler-Ross's five stages of grief [47,48] . These and other theories have
enriched the caring professions of medicine and nursing by offering novel ways of
understanding people and the world. Such is the case with the perspective provided by

26

Maslow, which offers a powerful conceptual framework enabling us to understand ICU

survivorship better and to tailor optimal interventions to promote better care.
Application of Maslow's hierarchy to attain comprehensive critical care success
The adaptation of Maslow's hierarchy of needs [23,24] to care during and after the
ICU (Fig. 1 B) could serve as a framework for changing the culture to accomplish a more
comprehensive type of success for our patients by creating interdisciplinary teams of
providers who comprehend and prioritize addressing higher ordered needs associated
with patient survivorship. These interdisciplinary teams--composed of physicians,
nurses, nurse practitioners, physician assistants, physical therapists, psychologists,
respiratory/occupational therapists, social workers, pharmacologists, and chaplains-would be able to join the patient and their family in a conversation regarding the
changing culture of what it means to provide holistic care to the patient ( Table 1 ). A
special emphasis on life after the ICU may also help patients and their families, as they
develop better awareness of the cognitive, psychologic, and physical disturbances that
often follow and which often seem unrelated to the patient's hospitalization or illness.
After discharge, patients are often immensely debilitated and unable to perform simple
physical activities, and they often have ongoing pain and discomfort for an extended
period [7-10] . Many patients also experience significant cognitive impairment at
discharge, which clinically is of a severity similar to Alzheimer disease or traumatic brain
injury [11-13,49,50] . Some of this new disability is often unavoidable after diseases such as
severe sepsis, but targeting the most likely iatrogenic and modifiable elements of harm
should mitigate post-ICU suffering.
Over the past decade, novel physical and cognitive interventions and
practices for critically
ill
patients
have
developed,
including
sedation
[27,31]
[51,52]
holidays
, delirium monitoring
,
early
mobility
and
physical
[15,18,53,54]
rehabilitation
, quality end-of-life care (ie, "good death" protocols) [55-58] ,
cognitive rehabilitation[59] , and post-ICU clinics [7,60] .
Post-ICU clinics, in particular, hold promise as they represent a bridge between
intensive care treatment and post discharge needs and are designed to focus on the
unique constellation of difficulties experienced by survivors of critical illness.
Using many of these physical and cognitive interventions described above, a
bundled approach to managing delirium, also known as the ABCDEs (found at
www.icudelirium.org), [61-64] was
developed for use in the
ICU.
The
ABCDEs
stand for Awakening trials (spontaneous awakening trials, a concept ranging from "less
sedation" to no sedation), Breathing trials (spontaneous breathing trials, referring to
stopping the ventilator everyday to see if it is still required), Coordination (between
27

nurses, doctors of pharmacy, respiratory therapists, and physicians) and Choice (of
sedative and analgesics), Delirium monitoring and management, and Early mobility,
Exercise, and Environment. Such evidence-based approaches [61] represent
opportunities for critical care providers to implement interventions that address patients'
needs more holistically. To focus on just 1 of these areas, for example, early studies
have demonstrated the importance of early occupational and physical activity and
movement in critically ill patients [14,15,65] as well as the use of early cognitive
rehabilitation training during hospitalization and after discharge [59,66] .
Addressing the
rehabilitation

highest

tiers

of

Maslow's

hierarchy

through

cognitive

For the sake of brevity and because this article is not meant as a review of all the
previously discussed literature, we will focus the remainder of the article on the area of
cognitive dysfunction and the novel concept of cognitive rehabilitation because it is the
newest aspect of these higher levels of Maslow's hierarchy to be
considered in critical care.
Cognitive rehabilitation has been defined in various ways. Cicerone et al [67] have
developed a widely used definition, which posits that it is "the systematic, functionally
oriented service of therapeutic activities that is based on assessment and
understanding of the patient's brain-behavior deficits." Cognitive rehabilitation is based
on 2 fundamental principles: (1) that the brain has the capacity to recover from insult or
injury (to a greater or lesser degree) and (2) that individuals have the potential to adjust
and adapt to the effects of brain damage, resulting in more effective coping [68] .
Although the "promise" of plasticity and spontaneous recovery may provide
reason for optimism for some brain-injured individuals, it clearly applies more to some
circumstances than others and depends on a number of factors such as the age of the
individual and the timing of rehabilitation [69] . Brain plasticity is strongly influenced by
age as reflected in animal models, which demonstrate that younger animals have
substantial neuronal changes in response to behavioral stresses in contrast to older
animals whose brains remain essentially unchanged [70] . Similarly, plasticity is timedependent as relatively large changes occur in the first weeks and months after brain
injury, but they gradually dissipate over time [69] . Based on these facts, individuals with
the greatest recovery potential after intensive care are likely younger and include those
older or younger individuals who engage in cognitive rehabilitation shortly after their
brain injury (but these are hypotheses that must be tested).
Although cognitive functioning may improve via cognitive rehabilitation, it is also
the case that patients who have experienced brain injury due to sepsis,
hypoxia, delirium, or related exposures can become more functional, even in the
28

absence of fundamental neuroplasticity, through the use of robust compensatory

strategies [71] . Compensatory strategies, in theory, can be used at virtually any time after
acute brain injury and are not dependent on the time-dependent factors that influence
neuroplasticity. Compensatory strategies refer to approaches by which individuals
leverage existing skills and abilities or develop new ones to "off-set" the impact of the
cognitive impairment after acute brain injury. For example, these may include the use of
a memory book, daily planner, or smart phone (schedule and alarms) to
compensate for impaired memory. Alternatively, compensation can involve an
adjustment of goals or desires, so that they are more compatible with post injury
abilities. [72] For a young brain-injured ICU survivor, it may be that the rigorous
mechanical engineering program he was pursuing at a large elite university is no longer
a viable choice in view of his difficulties with executive dysfunction, which contribute to
poor decision making and planning. Compensatory strategies, for him, might involve
harnessing his considerable interpersonal skills that are likely to have been relatively
less affected and using these to successfully engage in the study of sales and
marketing. Of course, such a change is often not accomplished easily and frequently
requires significant mental health treatment as people often experience depression and
anxiety in such circumstances and grieve their lost abilities. Indeed, the very process of
developing a central goal of rehabilitation for mind and body may help ICU survivors
develop a new post injury identity that corresponds more accurately to their post injury
abilities [73] .
The impact of early cognitive rehabilitation for ICU patients is not well studied, yet
holds promise as a means of improving cognitive outcomes. To date, a single pilot
investigation--the returning to everyday tasks utilizing rehabilitation networks (RETURN)
trial--focused specifically on the efficacy of the rehabilitation of executive dysfunction.
This randomized trial by Jackson et al, [59] focused on general medical and surgical ICU
patients and used a protocolized approach to rehabilitation called goal management
training. Baseline (preintervention) neuropsychologic testing results were well
matched in both intervention and control patients. At 3-month follow-up, intervention
patients demonstrated significantly improved executive functioning on the study's
primary outcome measure, which was executive function as measured with the Tower
test (P < 0.01) ( Fig. 2 ). Although the RETURN trial was a small pilot investigation with
clear limitations, it has demonstrated in a preliminary way that rehabilitation of executive
functioning in ICU survivors may be accomplished. Future studies should engage this
question more fully and with larger populations to determine definitively whether
executive impairments can be improved and sustained and to understand more fully the
potential benefits that integration of cognitive rehabilitation into critical care may yield.

29

Escaping the Fog of War and packaging the ICU patient more safely
In the movie Fog of War, Robert McNamara, secretary of defense for John
Fitzgerald Kennedy after having been president of Ford Motors, tells of his
observations in the early 1950s that too many people were dying incars. Engineers told
him, "It's a packaging problem. Take eggs, for example. When you buy eggs and take
them home, they aren't broken once in your kitchen because they were packaged
correctly. In this way, mechanical failure is our problem." McNamara replied, "If it's
mechanical failure then we might be involved. Let's get to the bottom of it!" And presto,
the 1956 model Ford introduced seatbelts to help save lives. "Unfortunately," McNamara
continued, "despite how logical it seemed, most people were against seatbelts, but
those who did use them saved their lives." In a similar way, ICU teams seem all too
often to be against "seatbelts," yet those who embrace change are often saving
lives. For example, commonly used sequencing protocols such as the ABCDEs [61,63] and
other evidence-based approaches designed to reduce iatrogenic injury from over
sedation, delirium, and immobilization are like seatbelts for our patients and ICU
teams. In this case, the "seatbelt" is actually the removal of chemical and physical
restraints to free the patient of tethers and achieve early "mobility" of the body and
brain. McNamara added a few steps to the production line at Ford that saved multitudes
of lives. Intensive unit care teams can do something analogous by implementing
programs such as the ABCDEs during bedside rounds to help patients escape the Fog
of War that the ICU introduces into their lives.
Conclusions
As advancements in critical care have translated into higher survival rates and
have shifted concerns from a primary focus on survival to a broader focus on quality of
life, clinicians and health care teams need to begin assessing the physical and cognitive
disabilities that often emerge after critical illness. In the years after ICU stay, millions of
survivors will face significant pain and psychiatric disturbances that often leave them
with a very poor quality of life. Improving ICU patient survivorship by identifying and
treating these legacies of critical care is the next step in the maturation of this
burgeoning field of medicine and surgery. Historically, advances in many fields of
inquiry, clinical and otherwise, have been bolstered by contributions from other
disciplines. In the spirit of interdisciplinary inquiry and growth, a widely studied model
from psychology, Maslow's hierarchy of needs, provides the framework and spark that
are needed to enhance translation of care with a patient-centered emphasis on the
physical and psychologic complaints experienced by survivors. The poor quality of
survivorship and dismantled lives of so many patients emerging from ICU care remain
an underrecognized public health problem that is not being addressed rapidly enough
because of our cultural blindness to "invisible" and unseemly iatrogenic contributions to
30

disease. The most senior critical care providers repeatedly remind others that years
ago, we had patients awake and walking in the ICU while on mechanical ventilation [74] .
Maslow's hierarchy principle, drummed up from previous days and others elements of
science, is apropos for critical care now. It is as if the author was talking about this
journey of those involved in the maturation of critical care when he wrote: "We shall not
seek from exploring. And at the end of our exploration, we will return to the place we
have been and know it for the first time." -TS Eliot

Table 1
Building connections between psychology and critical care
Maslow's stage

Typical patient problems

Physiologic

Basic
concerns
about
survival--frequently
expressed
by
family
members (as patients may
be unaware of their medical
situations)
Concerns about emotional
well-being in the context of
frequent nightmares and
delusions and whether the
ICU team can prevent their
conditions from worsening

Safety

Love/belonging

Esteem

Psychologic
intervention/solution
Clearly
and
concisely
explain to family members
the array of possible
outcomes
so
as
to
empower them
Provide
reality-orienting
interventions and active
emotional
support--keep
interventions frequent and
brief; work to address
cognitive distortions and
catastrophizing
Highlight the importance of
living in the "here and now"
and encourage strategies
to
assist
survivors in operating within
the boundaries of their new
limitations

Concerns about how much

support they will receive if
their critical illness persists
(eg, will people continue to
visit or will they forget about
me) as well as whether
they will "fit in" to old
communities now that they
have
"newly
acquired"
disabilities that may limit
them
Concerns about whether Institute interventions such
they can reach recovery- as cognitive rehabilitation

31

Self-actualization

related goals--eg, return to

vigorous activities or to
work as soon as they had
hope
Concerns about ability to
reconcile premorbid identity
with "new normal" and to
embrace a potentially new
identity

as a way of accelerating
recovery and increasing
mastery
Encourage
participation in formal
counseling, psychotherapy,
or support groups to
engage as a way of
encouraging
the
acceptance of a new
identity

SUMMARY
The intensive care unit (ICU) is not only a place where lives are saved; it is also a
site of harm and iatrogenic injury for millions of people treated in this setting globally
every year. These 2 realities engender a demographic imperative to address patient
safety in the critical care setting. This article addresses the medical community's
resistance to adopting a culture of safety in critical care with regard to issues
surrounding sedation, delirium, and early mobility. Although there is currently much
research and quality improvement in this area, most of what we know from these data
and published guidelines has not become reality in the day-to-day management of ICU
patients. This article is not intended to provide a comprehensive review of the literature
but rather a framework to rethink our currently outdated culture of critical care by
employing Maslow's Hierarchy of Needs, along with a few novel analogies.
REACTION
Delirium, as defined by the Mayo Clinic staff is a serious disturbance in an
individuals mental abilities that results in a decreased awareness of ones environment
and confused thinking. The article was focused on the care of these patients who were
admitted in the intensive care unit. Clinical managements especially nursing care in
patients with this cognitive disorder were remarked with various advancements and
future trends, and one of these is the application of Maslows model of the Hierarchy of
Needs. Maslows model proposes that there are 5 levels of needs, all of which must be
satisfied to have an effective effect or in simple terms, to promote the healthy well
being of the patient, this also provides the framework and spark that are needed to
enhance translation of care with a patient-centered emphasis on the physical and
psychological complaints experienced by survivors. Each of these needs is to be
studied and therefore be applied to the patients in ways that raised problems may be
32

solved by then again, psychologically and physically. In accordance to the care,

cognitive rehabilitation is also observed whilst implementing various interventions. Now
what is cognitive rehabilitation? Cicerone et al have developed a widely used definition
that is the systematic, functionally oriented service of therapeutic activities that is based
on assessment and understanding of the patient's brain-behavior deficits." By
understanding the treatments we could easily see the relationship of these two
managements shedding light on the improvements of patient care. Early rehabilitation
with the implication of Maslows model may project effective interventions including
patient safety and supportive care. The impact of early cognitive rehabilitation for ICU
patients is not well studied, yet holds promise as a means of improving cognitive
outcomes. This treatment allows the patients to become functional as they were
oriented on a daily basis in their surroundings and activities. With this, the application of
Maslow's Hierarchy of Needs will really help propel health care professionals toward
comprehensive holistic care of the whole person not merely for survival but toward
restoration of pre-illness function of mind, body, and spirit.

33

 DEMENTIA
Understanding Nurses' Decisions to Treat Pain in Nursing Home Residents with
Dementia
Gilmore-Bykovskyi, Andrea L, MS, RN; Bowers, Barbara J, PhD, RN, FAAN. Research
in Gerontological Nursing 6.2 (Apr 2013): 127-38.
Pain is a commonly occurring symptom among older adults, which is largely the
result of functional age-related changes and the development of chronic conditions
(American Geriatrics Society [AGS] Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009 ). Estimates of
the prevalence of daily pain in community-dwelling older adults range from 32% to 56%,
and estimates of pain in older adults living in nursing homes (NHs) range from 60% to
70% (Kruger & Stone, 2008 ; Takai, Yamamoto-Mitani, Okamoto, Koyama, & Honda, 2010 ). Untreated and undertreated
pain in older adults has a serious negative impact on health, functioning, and quality of
life, contributing to depression, social isolation, sleep disturbances, and functional and
cognitive impairment (Gibson & Weiner, 2005 ; Herr & Garand, 2001 ). Older adults living in NHs are at
high risk forexperiencing poor pain management as a result of system-related barriers
such as incomplete medical records and highly burdened staff with limited resources
(Ferrell, 2000 ). This risk increases further for residents withdementia whose ability to reason
and communicate their needs is often compromised, diminishing their ability to
recognize and report pain (Bachino, Snow, Kunrk, Cody, & Wristers, 2001 ; Horgas & Elliot, 2004 ).
Research has consistently documented the high prevalence of underassessment
and pharmacological undertreatment of pain in NH residents with dementia (Reynolds, Hanson,
DeVellis, Henderson, & Steinhauser, 2008 Williams, Zimmerman, Sloane, & Reed, 2005 Wu, Miller, Lapane, Roy, & Mor, 2005
;
;
).
Misconceptions about pain and aging, stoical attitudes, inadequate training, and
underuse of appropriate assessment tools present barriers to effective pain assessment
and treatment in older adults with dementia (McAuliffe, Nay, O'Donnell, & Fetherstonhaugh, 2008 ).
Collectively, this research has made a compelling case for the need to develop and
implement more suitable pain assessment strategies for individuals with dementia.
During the past decade, researchers have made significant advancements in this area
through the development, evaluation, and dissemination of numerous assessment tools
designed to recognize behavioral pain indicators in nonverbal older adults ( Herr, Bjoro, &
Decker, 2006 Herr, Bursch, & Black, 2008 Herr, Bursch, Ersek, Miller, & Swafford, 2010
;
;
). Despite the availability of these
tools and clear guidelines for their use, an alarming number of residents are still
experiencing poor pain management ( AGS Panel on the Pharmacological Management of Persistent Pain in Older Persons,
2009 American Medical Directors Association, 2009 Hadjistavropoulos et al., 2011
;
;
).

34

Research suggests there is a discrepancy between nurses' identification of pain

indicators in people with dementia and their decisions to provide analgesic agents
(Kaasalainen et al., 1998 ; McCaffery, Ferrell, & Pasero, 2000 ). Horgas and Tsai (1998 ) found that even when
controlling for number of painful conditions, NH residents with cognitive impairment
received significantly fewer analgesic agents than residents without cognitive
impairment. Research has focused largely on the assessment of pain, but few empirical
studies have examined reasons for the continued inadequacy of pharmacological
treatment of pain for NH residents with dementia. One grounded theory study
conducted by Kaasalainen et al. ( 2007 ) examined physicians' and nurses' attitudes and
beliefs about prescribing and administering pain medication in long-term care. They
identified several barriers to effective treatment including under recognition of pain,
uncertainty regarding pain assessment and diagnosis, and discomfort with opioid use
( Kaasalainen et al., 2007 ). No study, however, has explored nurse decision making about
providing analgesic agents to individuals with dementia. Identifying reasons for the
inconsistency between nurses' identification of pain indicators in residents
with dementia and the actions they take related to treatment can inform interventions to
improve pain management for this vulnerable population. Please note that throughout
this article treatment refers to the provision of analgesic agents, while acknowledging
that other treatment modalities are available.
The purpose of this study was to examine how nurses make decisions to
pharmacologically treat pain in NH residents with dementia, as well as to identify the
conditions that influence treatment decisions, and to develop a conceptual model that
can guide future research and clinical practice.
Method
Research Design
This study used a qualitative design--Grounded Dimensional Analysis--to explore
the understandings nurses have about pain in individuals with dementia, the actions
they take in relation to those understandings, and how the two are related ( Caron & Bowers,
2000
). Another major goal of this research was to identify conditions that influence
nurses' actions related to pain management. These aims are well suited for Grounded
Dimensional Analysis (Caron & Bowers, 2000 ; Schatzman, 1991 ), a qualitative methodology developed
as an alternative to grounded theory. It is similar in that it shares a symbolic
interactionist foundation and is designed specifically to generate theory about how
social understandings guide actions and to identify consequences associated with
various actions. The end product of Grounded Dimensional Analysis is a conceptual
model that explains the phenomenon of interest ( Bowers & Schatzman, 2008 ).

35

Sample and Setting

The only eligibility criterion for nurse participants was that they be licensed
nurses (licensed practical nurses [LPNs] or RNs) with experience caring for NH
residents with dementia. Both LPNs and RNs were included because LPNs compose
approximately half of the licensed nurse workforce in NHs ( Rantz et al., 2004 ), and despite
clear differences in scope of practice, in NHs, LPNs often function in a capacity similar
to RNs (Corazzini et al., 2010 ). The study was determined to be exempt from review by the
University Institutional Review Board as no identifiable patient or nurse information was
collected. As a result, no demographic information was collected from participants
outside of what was needed to ascertain eligibility. Researchers worked in collaboration
with directors of nursing to recruit participants.
Interviews were conducted with participants in a private room at their place of
work at a time convenient for them. Participants were asked to participate in one to two
interviews and received a $15 honorarium per interview. Interviews were audio recorded
and transcribed verbatim. Two participants were interviewed twice; these follow-up
interviews were used to engage in verification strategies, such as member checking, to
ensure fit with the developing conceptual model, and to pursue new questions that
arose during analysis.
Both convenience and theoretical sampling were used throughout the study.
Participants were recruited by convenience sampling through e-mails from their director
of nursing, flyers posted in designated workspaces, and an announcement about the
study at one staff meeting. Theoretical sampling involves the pursuit of data that will
provide opportunities for constant comparative analysis--a process fundamental to
grounded theory analysis ( Strauss, 1987 ). Constant comparative analysis involves the
pursuit of variability and complexities inherent in the phenomenon being studied (Strauss,
1987
). Theoretical sampling can be achieved through identification of participants with
relevant experience or through modifying interview questions to maximize comparisons,
sampling for variations in experiences or events with a single participant. In this study,
theoretical
sampling
was
pursued
primarily
by
modifying
interview
questions. For example, if a participant recounted a treatment decision involving a
resident with very severe dementia who recently underwent surgery, the investigator
would explore how that differed from a resident with no dementia or mild dementia postsurgery. Thus, asking a single participant to provide details of the two separate
situations and to explain and compare how each was approached provides a
comparative sample. The researchers relied primarily on theoretical saturation of the
core category to determine the appropriate sample size but also considered other
important data elements, including the quality of the data (which was rich and
descriptive), the scope of the core category of interest (which was specific and not too
36

broad), the use of shadowed data (which was fairly common), and the complex nature
of the topic (which is complex) ( Morse, 2000 ).
Data Collection and Analysis
In conducting Grounded Dimensional Analysis, data collection and analysis occur
simultaneously and cyclically ( Schatzman, 1991 ; Strauss, 1987 ). That is, data are analyzed
following each interview, allowing the researcher to pursue questions in subsequent
interviews that are informed by the development of the conceptual model. Analysis
progressed through several nonlinear phases: open, axial, and selective coding. Open
coding focused on the discovery and description of categories and their characteristics
(dimensions). Axial coding involved the exploration of conditions that influence the
social process (pain management) and consequences related to different conditions
and decisions. The primary goal of axial coding was to explore the interactions between
different dimensions, conditions, and decisions in a variety of social situations that
influenced these relationships. After conducting several very open interviews using
these analytic procedures, selective coding became the focus of analysis. During
selective coding, identifying a central social process or core category became the
primary goal of analysis.
Toward the beginning of the study, line-by-line open coding techniques were
used to analyze the data to ensure the products of analysis were consistent with the
data (Strauss, 1987 ). The first of several interviews opened by asking participants broad,
nondirective questions such as: "Tell me about your experience working as a nurse."
Most participants began by describing positions they have held and
different nursing duties such as assessment and treatment. Other initial categories that
resulted from open coding were supervising, becoming aware of problems, and
identifying different sources of information through which nurses' became aware of
issues such as pain. As interviews progressed and analysis shifted toward axial coding,
more direct questions were asked about nursing duties surrounding pain management,
which highlighted nurses' categorizing of residents (i.e., dementia/no dementia, drug
seeking/not drug seeking, short-term stay/long-term stay) and pain (visible/obvious or
nonvisible/not obvious). Participants also described inability to communicate due to
other conditions, such as aphasia or trauma, as challenging for pain management;
however, this study focused only on communication difficulties due to dementia.
These categories informed subsequent theoretical sampling decisions, interview
questions, and selection of the core category: responding to pain that manifests as a
change in behavior. Data collection and analysis continued until this core category was
theoretically saturated. Throughout the research process, conceptual diagrams were
developed and continually revised in light of new evidence. These conceptual diagrams
37

were also used for member checking at different points in theory development. Member
checking was achieved by presenting conceptual diagrams to participants at the end of
interviews to verify accuracy of the relationships among categories and to stimulate
identification of other relevant categories not previously identified. Several
methodological strategies were implemented to ensure the data analysis procedures
were rigorous and appropriately represented the data collected. Among these were the
use of an interdisciplinary research group to analyze data and member checking. The
first author (A.L.G.-B.) also maintained ongoing memos to document theoretical and
methodological decisions.
Findings
Summary of Findings
Fifteen in-depth interviews were conducted with 13 nurses from four
skilled nursing facilities in Wisconsin. Three were LPNs and 10 were RNs. Across
findings, there were no notable differences in responses from LPN versus RN
participants. All participants worked in facilities that were part of a larger
continuing care retirement community. Interviews ranged from 40 to 96
minutes in length.
A conceptual model (Figure ) was developed to illustrate the process nurses
engage in while identifying and deciding whether or not to treat pain in NH residents
with dementia. The model describes how nurses' perceived level of certainty regarding
suspected pain influences treatment decisions. Nurses perceived level of certainty
about the presence of pain was the most significant factor in determining whether and
how quickly a resident's pain would be treated pharmacologically. Resident
characteristics, as well as presence or absence of an obvious reason for pain,
influenced nurses' levels of certainty regarding pain. Visible/obvious reasons for pain
were considered to exist when a resident had a condition or experience for which pain is
widely known to be an expected outcome, such as recent surgery. Major concepts of
the conceptual model are defined with examples in Table 1 .
The most salient resident characteristics were whether a resident: (a) was a longor short-term stay resident, (b) had dementia, (c) had a history of drug seeking, and (d)
was actively dying (Table 2 ). Nurses described engaging in different assessment and
treatment procedures in response to whether they had generally high or low levels of
certainty regarding the presence of pain, leading to two distinct treatment trajectories:
Responding to Uncertainty and Responding to Certainty ( Figure ). The Responding to
Uncertainty trajectory led to treatment delays and generally occurred with patients who
were long-term stay and/or had dementia and/or had a history of drug seeking and/or
38

had no visible or obvious reason for pain. Responding to Certainty led to prompt
treatment and usually occurred with residents who were short-term stay and/or did not
have dementia and/or were actively dying and/or had a visible or obvious
reason for pain.
Nurses' identification of pain in residents with dementia relied heavily on the
display of three types of pain indicators: (a) behaviors suggestive of pain, (b) behaviors
highly suggestive of pain, and (c) general behavior changes (Table 1 ). Nurses
described general behavior changes as indicative of possible pain but also potentially
related to other causes. Examples of general behavior changes included withdrawal,
restless behaviors, and negative vocalizations. Nurses described these different types
of pain indicators when directly asked how they perceive signs of pain in people
with dementia. Without guidance from the interviewer, however, nurses conceptualized
any type of pain indicator exhibited by a person with dementia as a behavior change.
Even in situations when residents with dementia self-reported pain, nurses still
conceptualized their pain and these reports as representing a change in normal
behavior. Nurses felt uncertain about the reliability of physical symptom complaints from
those with dementia and about whether pain was the cause of behavior changes. As a
result, even though they identify pain indicators in residents with dementia, nurses
generally had very low levels of certainty regarding suspected pain for these residents.
The presence of pain indicators was not routinely sufficient to trigger pharmacological
intervention. In response to suspected pain, nurses attempted various, non-sequenced
interventions to try to relieve behavior changes, which did not always include analgesic
agents. As a result of this "trial-and-error" process, analgesic agents provided to
residents with dementia would often be delayed.
The goals of assessment and treatment also varied in response to whether or not
a resident had dementia. In the absence of dementia for both characteristics associated
with certainty and uncertainty, the purpose of assessment and treatment activities was
to confirm certainty regarding pain and/or verify effectiveness of treatment. In the
presence of dementia, however, the goal of assessment and treatment shifted toward
returning the resident to baseline functioning by reducing or eliminating behavioral
symptoms. Interestingly, although nurses felt very uncertain about their ability to confirm
suspected pain in residents with dementia, they did not pursue certainty or routinely
document effectiveness of interventions for residents with dementia. Nurses expressed
feeling that it was nearly impossible to establish certainty regarding the underlying
causes of pain indicators in residents with dementia. In situations when residents
displayed pain indicators highly suggestive of pain, nurses suspected pain more
strongly and were more likely to provide prompt treatment, although the focus of
treatment remained returning the resident to baseline.

39

Responding to Uncertainty
Consistently, residents (a) with dementia or (b) who were perceived by nurses to
be drug seeking or (c) or were long-term stay residents, or (d) had no obvious or visible
reason for pain fell into the Responding to Uncertainty trajectory. This trajectory
produced further, more comprehensive assessments, and delayed or no treatment.
While treatment delays were not explicitly measured in this study, they were
spontaneously reported to occur by most participants. The extent of treatment delays
was elicited by examining additional processes nurses described engaging in when
responding to uncertainty, which invariably took additional time to complete.
Long-term stay residents were understood to have conditions that might
contribute to the experience of persistent pain. However, because pain generally was
not anticipated in long-term stay residents and usually was not obvious or visible,
nurses considered its occurrence to be abnormal and necessitate more extensive
assessment:
Most of our patients here are rehab...they've had new hips, knees, they've had
strokes. They're tiny little frail bodies, I mean they have to have pain.... Just plain longterm folks those are people that are there to live...they may have arthritis,
Parkinson's...and many of those diseases result in pain...but it takes a good body
assessment to figure out why someone [who is] long term and [who is] not supposed to
be in pain, why are they in pain?
Nurses considered pain to be easier to assess and treat in residents with visible
or obvious reasons for pain and in residents who can accurately report the effectiveness
of treatment. Nurses described feeling highly uncertain regarding pain in people
with dementia due to a perceived inability to accurately interpret and answer
assessment questions, and they believed it was impossible to ever achieve
certainty in the absence of a more obvious reason for pain:
And we do have a lot of people with chronic pain too like arthritis, neuropathies,
old fractures...scheduled pain meds are for people with the more severe pain...some of
the long-term people can't speak anymore then you're relying more on whether they
grimace or whether they moan, look comfortable...it's harder to judge their pain. They
can't tell you so even if you think they're in pain--you don't know. Easy is when they can
tell you and they're showing the signs and symptoms. They have the evidence, they
have had surgery, they've got a gaping wound, they're telling you it's a 10 or an 8 and
when you see results--you give them the pain pill, you go back and they say "Well now
it's a 2."...those are the easy ones.

40

Whether a resident is considered to be drug seeking appeared to have more

direct implications for the time to treatment. Residents with a history of drug seeking or
who display drug-seeking behaviors (e.g., routinely asking for as-needed pain
medication in more frequent intervals than ordered while not appearing to have
substantial pain) were described as experiencing additional assessments and
delays in treatment: "I'm not gonna run down there and give them that pain pill, they can
wait.... [I] may be a little slower."
Resident and pain characteristics associated with uncertainty had an additive
effect on the extent of treatment delays. Behaviors highly suggestive of pain generally
resulted in more prompt analgesia; however, when added to a patient's dementia, no
obvious reason for pain, or history of drug seeking, nurses experienced increased
uncertainty, which produced greater treatment delays. Of the four characteristics
associated with uncertainty, dementia was described as being the greatest deterrent to
prompt pain treatment. Residents with no obvious reason for pain, those with a history
of drug seeking, or long-term stay residents withoutdementia were described as
receiving eventual but less automatic treatment, which may even have taken the form of
deliberately delayed treatment. Comparatively, residents with dementia were described
as very likely to receive delayed treatment and in some instances unlikely to receive any
treatment.
Nurses' Understanding of Pain and Decisions to Treat Pain in Residents
with Dementia
Nurses often learned about suspected pain in residents with dementia as the
result of a behavior change or because of a resident complaint. Regardless of
variation in the symptoms or complaints of suspected pain in residents with dementia, it
was almost exclusively discussed and responded to as representing a change in
behavior. Only one deviation to this response was described, which involved residents
who both had dementia and were actively dying--a characteristic that led to the
Responding to Certainty trajectory. Nurses described feeling very uncertain regarding
their ability to confirm the presence of pain and its etiology for residents with dementia.
Nurses' strategies for assessing pain in residents with dementia varied, and in some
instances, they did not attempt to gather any verbal information:
It's a lot easier when they're [cognitively] intact to just explain to them on a
scale.... I don't even ask the question of someone who's demented because they
wouldn't understand it anyway...so I look at their body language, their facial
expressions, how they're responding to you, to your touch, to your trying to care for
them.

41

Changes in behavior were consistently considered to be indications of some

underlying discomfort, psychosocial unrest (e.g., altercation with another resident), or
pathophysiological change. Nurses considered pain to be only one of a number of
potential causes for behavioral changes and explained it is likely that a combination of
these factors contributed to behavior changes. In response to suspected
pain in residents with dementia, nurses embarked on a trial-and-error approach that
involved trialing different combinations of pharmacological and non-pharmacological
interventions to relieve the underlying discomfort. The interventions they described
included toileting, adjusting the room to suit resident preferences, offering a low dose of
acetaminophen, repositioning, adjusting temperature and thermal comfort, increasing or
decreasing stimulation, taking the resident outdoors or changing the environment,
offering food, and checking for signs of acute illness (e.g., pneumonia, urinary tract
infection [UTI]) if behaviors deviated from baseline. Interestingly, although nurses did
not think it was possible to pinpoint the exact causes of the behavior change, they
considered a return to baseline to indicate that some combination of interventions
performed during the trial-and-error process had relieved the causes of behavior. The
following quotation elucidates this process:
Well with the demented resident, I think you have to narrow it down. You have to
toilet them. You have to bring them food. You have to offer a back rub. Some of them a
pain pill isn't going to help if they still have to go to the toilet, if they're still hungry. You
turn on the light, I might get ice cream. I might turn on the television, along with that I
would give them a pain pill...if they're restless or have a temp, maybe they're having
discomfort from a UTI. So it's a matter of elimination.... It is kind of a hit and miss.
Nurses continued the trial-and-error process until the resident's behaviors
resolved. Most nurses stated that there is no specific order to these interventions, but
some discussed adopting an individualized approach, wherein they would first try
interventions known to be successful for a particular resident in the past. If significant
time passed without resolution of the behaviors, nurses would contact a supervisor or a
nurse practitioner/physician. Some nurses provided estimates of this delay as
commonly being two to three 8-hour shifts. Nurses did not consider the use of analgesic
agents harmful in the event that pain cannot be established as the cause for behavior
change: "There is no order, you have to deal with what's pertinent at hand.... I may give
them the pain pill.... I don't think we're hurting anybody by giving them a pain pill if they
don't have pain."
Residents who displayed general behavior changes that were vague in nature
(e.g., being withdrawn or disengaged) were described as being least likely to receive
analgesic agents or as experiencing the longest delays in time to treat. Hypoactive
behavioral changes were also less likely to suggest the need for pain treatment, and
42

nurses highlighted the importance of developing relationships with residents to facilitate

recognition of these more silent presentations of behavior change:
I think that the demented resident who cannot complain sometimes is
forgotten...especially the ones that are quiet. I think the ones that strike out and are
combative, any nurse can [figure out] maybe the pain is causing this behavior.... There
are so many things we can look at with dementia. Do they need to go to the toilet? Are
they hungry? Is there something wrong with the room that they're afraid of? Building a
trustful relationship with the staff is very important for [pain] management.
The consequences of the Responding to Uncertainty trajectory for a resident
with dementia may include under recognition and under treatment of pain, as well as
treatment delays. Because many interventions occur simultaneously and little effort is
made to evaluate the effectiveness of individual interventions, it is unclear whether
nurses are able to establish patterns in individual residents' behaviors that would
facilitate the development of more individualized responses. Only when behavior
changes remain unresolved and pain is the suspected cause did nurses describe
documentation of treatment and outcomes over a period of time. Nurses said it would
often take 1 to 2 days for a pattern to be established that would merit implementing new
pain medication orders.
Responding to Certainty
Nurses
described
a
process
of
prompt
treatment for residents
without dementia and/or those who are short-term stay and/or those who are actively
dying and/or residents considered to have visible or obvious reasons for pain. Nurses
described responding to obvious reasons for pain with high levels of certainty,
consequently expediting treatment. Although nurses recognized that not all short-term
stay residents are cognitively intact with obvious reasons for pain, they consistently
dichotomized long- and short-term stay residents into different treatment trajectories.
Suspected pain that occurs in the context of resident and pain characteristics
associated with certainty was responded to by conducting a brief assessment (generally
by using a 0-to-10 pain rating scale), offering prompt treatment, and following up to
confirm certainty and/or verify effectiveness (Figure ).
The absence of dementia produces a strong influence on decisions to treat
because of the ability of resident without dementia to communicate. Even if a
visible/obvious reason for pain was not apparent and nurses had a low level of certainty
regarding suspected pain, residents without dementia were reported to receive prompt
treatment for two reasons: (a) because they could reason and communicate clearly and
(b) because they were able to advocate for themselves.
43

Visible/Obvious Pain: A Dominant Condition

The presence of a visible and obvious reason for pain was a dominant condition
that could shift residents who would generally be prone to the Responding to
Uncertainty trajectory into the Responding to Certainty trajectory. For example, a
resident with severe dementia with a recent surgically repaired hip fracture or who is
actively dying would be considered to have obvious and visible pain and, therefore,
would be more likely to receive prompt analgesic treatment. However, nurses
commented that, overall, residents with obvious reasons for pain and dementia may
receive somewhat less treatment for other reasons, including limited or absent ability to
verbalize pain or request treatment, only being formally assessed by a nurse once per
shift, and hypoactive or vague presentation of pain.
Discussion
Findings from this study provide important insights into how nurses conceptualize
pain in NH residents with dementia and their decisions to provide pharmacological
treatment in several skilled nursing facilities in Wisconsin. The findings also highlight
reasons for continued inadequate pain treatment for NH residents without dementia with
various chronic diseases that were perceived by nurses in this study to have few
obvious reasons for pain. Nurses interviewed in this study were most uncertain about
the likelihood of pain in residents with dementia, who were also at greatest
risk for experiencing
underassessment,
under
treatment,
and
delayed
treatment for pain.
Participants' uncertainty regarding the accuracy of self-report in residents
with dementia was exacerbated by a general inability to differentiate between behavioral
presentations that merited analgesic interventions and those that did not. Nurses in this
study described the reality of pain management from their perspective. This
conceptualization of pain sheds some light on potential reasons for continued
disproportionately low levels of analgesic treatment for NH residents with dementia.
Under the condition of dementia, nurses encountered pain in the context of behavior
change. The actions they undertake, specifically the process of trial and error to relieve
behaviors, are likely responsive to the irregularity, vagueness, and complexity of the
behaviors exhibited.
Practice recommendations highlight the use of non-pharmacological
interventions as first line therapy for behavioral symptoms of dementia, as the
antipsychotic agents often used to address these symptoms are not
effective in improving functioning, decreasing care needs, or improving quality of life,
and are associated with numerous adverse side effects ( Salzman et al., 2008 ). There is
44

growing recognition, however, that other pharmacological interventions, particularly

analgesic agents, are both necessary and appropriate, as research suggests that acute
physical problems such as pain are a common cause of behavioral symptoms ( Kovach et al.,
2006 Kovach, Logan, Simpson, & Reynolds, 2010
;
). Nurses in this study did not prioritize assessment and
treatment of physical problems but did consider numerous nonphysical
etiologies for behavioral changes, such as psychosocial or environmental imbalance.
This approach may be reflective of care foci in the NH environment, where the
basis for many care interactions is a relationship between staff and the resident, rather
than
the
intersection
of
illness
and
treatment
more
commonly
seen in acute care settings. To that point, it is important to add that all nurses in this
study described dedicated and thorough attempts to maintain residents' well-being by
meeting what they considered to be a variety of unmet needs. This suggests important
implications for future intervention work: acknowledging and appreciating nurses'
genuine concern regarding residents' needs is likely central to achieving the buyin necessary to effect change in nurses' pain management practices. More empirical
examination of how nurses in this environment encounter and respond to pain indicators
and dementia-related behavioral symptoms is needed to ensure that interventions to
improve pain and symptom management are responsive to the real-world needs of the
NH work environment.
Nurses in this study did not have clear procedures for assessing pain,
responding to pain indicators and behavior changes, or prioritizing interventions. It is
also clear that a large degree of inconsistency abounds regarding the provision of
different interventions in response to pain indicators and behavioral symptoms, which
suggests that nurses might benefit from easily-accessible decision-support algorithms
that integrate guidelines for both pain and behavioral symptom management. Algorithms
could help nurses decide when to implement which types of interventions (i.e.,
pharmacological and non-pharmacological) and in what order. An example of a
decision-support intervention that follows an algorithmic model is the Serial Trial
Intervention, a clinical protocol for assessing and treating unmet needs
symptoms in people with severe dementia ( Kovach et al., 2006, 2012 ).
Findings from this study suggest that uncertainty about the likelihood of pain and
accuracy of self-report in people with dementia present major barriers to prompt
treatment. Similar to findings from other studies, uncertainty played a significant
role in staff members' perception of pain ( M.E. Clark, 2004 ; Kaasalainen et al., 2007 ). Findings from the
current study expand this knowledge by providing information about how uncertainty
influences treatment: In uncertain situations, nurses in this study described deliberately
delaying treatment decisions or negating treatment in particular situations, such as with
residents exhibiting drug-seeking behaviors. This finding suggests that certain attitudes
or beliefs toward drug-seeking behaviors are a clear barrier to proper pain
45

management. Although people with mild to moderate cognitive impairment are able to
provide reliable pain reports over time ( Weiner, Peterson, Logue, & Keefe, 1998 ), some nurses in this
study felt so uncertain about the reliability of self-report in residents with dementia that
they reported regularly failing to ask any direct questions about pain.
Nurses in this study felt little to no need to validate the effectiveness of treatment
but rather focused their efforts on returning the resident to baseline. This practice limits
the degree to which future interventions can be individualized. Consistent with findings
from other qualitative studies ( L. Clark, Jones, & Pennington, 2004 ;Kovach, Griffie, Muchka, Noonan, & Weissman,
2000 Parke,
1998
;
), personal knowledge and the use of an individualized
approach for addressing behavioral changes was identified by some nurses as
particularly important for identifying and responding to hypoactive behavioral changes.
Decision-support systems capable of accommodating and even recommending
individualized assessment and treatment approaches may be particularly useful, as
these nurses described very little documentation of results from any approaches.
Findings from this study highlight an urgent need to improve longterm care nurses'
understanding
of
evidence-based
pain
management
guidelines in older adults, particularly for those with dementia and chronic pain.
Nurses in this study held numerous misconceptions regarding pain in older adults,
which presented barriers to adequate pain management. Participants understood that
many residents had comorbid chronic conditions but did not consistently associate older
age and chronicity with increased risk for persistent pain. The under recognition of
pain in long-term care residents likely to experience persistent pain by nurses in this
study represents an alarming gap between current evidence and practice ( AGS Panel on the
Pharmacological Management of Persistent Pain in Older Persons, 2009
).
The progression of assessment techniques nurses used rarely followed
evidence-based recommendations. The Hierarchy of Pain Assessment Techniques
outlines these steps: (a) attempt some form of self-report, (b) search for potential
causes, (c) observe patient behavior, (d) obtain proxy reports if available, and (e)
attempt an analgesic trial ( Hadjistavropoulos et al., 2007 ; Herr, Coyne, McCaffery, Manworren, & Merkel, 2011 ). Some
nurses made no attempts to obtain self-report from residents with dementia, and most
began assessment efforts by initiating interventions to relieve behaviors devoid of any
analgesic trial. Guidelines further recommend regular reassessment and documentation
( Herr et al., 2011 ), which were rarely described by nurses in this study.
The only pain assessment tools nurses described were the 0-to-10 Numeric Pain
Intensity Scale (McCaffery & Pasero, 1999 ) and the Faces Pain Scale ( Hicks, von Baeyer, Spafford, van Korlaar, &
Goodenough,
2001
). No mention was made of other validated, nonverbal pain
tools for use in advanced dementia,
such
as
the
Pain
46

Assessment in Advanced Dementia Scale (Warden, Hurley, & Volicer, 2003 ), the NonCommunicative Patient's Pain Assessment Instrument ( Snow et al., 2004 ), or the Pain
Assessment Checklist for Seniors with Limited Ability to Communicate ( Fuchs-Lacelle &
Hadjistavropoulos, 2004
). Many of these evidence-based tools and instructions for their use are
available free on the GeriatricPain.org website (http://www.geriatricpain.org), but when
asked, no participant was able to name any other pain assessment tool used in their
facility. Exploring in a larger sample the extent of long-term care nurses' knowledge of
nonverbal pain tools and reasons for the under application of evidence-based pain
assessment practices in NHs can help identify areas of need for translational research.
NHs receiving reimbursements from the Centers for Medicare & Medicaid
Services must demonstrate that all residents with pain symptoms or who have the
potential for pain (a) have their pain recognized and anticipated, (b) have existing pain
and its causes evaluated, and (c) manage or prevent pain consistent with clinical
standards of practice and the residents' preferences ( McSpadden, 2010 ). Faced with the
complexity of dementia and dementia-related behaviors, however, nurses in this study
did not have a strong enough understanding of pain and behavioral symptom
management to meet these goals. Overwhelmingly, nurses expressed strong feelings
about the importance of providing comprehensive pain treatment, which strongly
suggests that unwillingness to treat is not the root cause of this problem. Interventions
geared toward improving decision making and decision support among nurses need to
go beyond providing education and address the need for additional system supports
and facility-level integration of appropriate pain management practices.
Limitations
The findings of this study must be interpreted in light of its limitations. This study
included a small sample of licensed nurses who all worked in a geographically similar
area. No demographic information was collected and no participant observation took
place. As a result, the researchers are unable to establish, with certainty, consistency
between nurses' reported treatment patterns and their actions.
Conclusions and Future Directions
Findings from this qualitative study provide an understanding of treatment
decisions regarding pain from nurses at four skilled nursing facilities in Wisconsin. This
study provides further evidence of low levels of adherence to evidence-based pain
management practices in NHs and expands the understanding of possible
reasons for continued under treatment of pain in residents with dementia, according to
the nurses' perspective. This study also expands the understanding of the
interrelationships among resident, pain, and provider characteristics related to pain
47

treatment decisions. Examining nurses' pain treatment decision making practices with a
larger sample and an expanded care area is suggested.
SUMMARY
Nursing home (NH) residents with dementia continue to receive inadequate pain
treatment. The purpose of this qualitative study was to examine how nurses make
decisions to pharmacologically treat pain in NH residents with dementia. Nurses
experienced varying levels of certainty regarding suspected pain in response to
particular resident characteristics and whether pain was perceived as visible/obvious or
nonvisible/not obvious. Nurses felt highly uncertain about pain in residents
with dementia. Suspected pain in residents with dementia was nearly always
conceptualized as a change in behavior to which nurses responded by trialing multiple
interventions in attempts to return the resident to baseline, which despite current
recommendations, did not include pain relief trials. Residents with dementia were
described as being at greatest risk for experiencing underassessment, under treatment,
and delayed treatment for pain.
REACTION
As it was stated, suspected pain in patients with dementia approximately
conceptualizes as a change in behavior that were responses of multiple treatments and
interventions in attempts to return the patient to him/her usual self. Nevertheless, when
pain is present our job as care providers entails the alleviation of the pain that is
experienced either objectively or subjectively. This is why assessment is very important
as well as it is crucial as to how we may come to manage the problem
pharmacologically and non-pharmacologically. But for patients with dementia, they may
include characteristics such as presence or absence of an obvious reason for pain,
which would greatly influence nurses' levels of certainty regarding pain. Visible/obvious
reasons for pain were considered to exist when a resident had a condition or
experience for which pain is widely known to be an expected outcome. With this, we
may say that the pain experience is brought by a change in the behavior of the patients,
and this would also question if pharmacologic treatment would be necessary or nonpharmacologic managements may help with the alleviation of pain alone. We should
adopt to the patient, narrowing them down to know if ever behavioral changes may
occur, and simple managements such as toileting, adjusting the room to suit resident
preferences, repositioning, adjusting temperature and thermal comfort, increasing or
decreasing stimulation, taking the resident outdoors or changing the environment,
offering food helps in controlling their pain. It was also stated in the article that patients
who displayed general behavior changes that were vague in nature (e.g., being
withdrawn or disengaged) were described as being least likely to receive analgesic
agents or as experiencing the longest delays in time to treat. Hypoactive behavioral
48

changes were also less likely to suggest the need for pain treatment, and nurses
highlighted the importance of developing relationships with the patients. Communication
and rapport is essential in managing pain to patients with dementia. The goal now of
assessment and treatment interventions shifted toward pain and returning the patient to
baseline functioning by understanding, then reducing or eliminating behavioral
symptoms that may be the root of the predicament.

49

 AMNESTIC DISORDER

Benefits of training working memory in amnestic mild cognitive impairment:

specific and transfer effects
Carretti, Barbara ; Borella, Erika ; Fostinelli, Silvia; Zavagnin, Michela. International
Psychogeriatrics 25.4 (Apr 2013): 617-26.
Mild cognitive impairment (MCI) is defined as a transitional stage between normal aging
and dementia. In 1999, Petersen and colleagues (Petersen et al., 1999) suggested that
MCI is characterized by impaired memory and intact basic functional abilities of daily
living; some studies also suggest that MCI can be considered as prodromal of the onset
of Alzheimer's disease (AD) (e.g. Petersen et al., 2001). In the last decade, these
diagnostic criteria have attracted a great deal of interest due to the importance of
identifying cognitive dysfunction in the predementia phase, before functional impairment
becomes apparent. In 2006, the International Working Group on MCI revised its criteria
with a view to distinguishing between subtypes of MCI based on cognitive dysfunction:
in particular, a distinction has been drawn between an amnestic condition (amnestic
mild cognitive impairment, aMCI) and a non-amnestic (naMCI) disorder in which single
and multiple domains unrelated to memory are impaired (Portet et al., 2006).
The main criterion for diagnosing MCI is therefore the presence of a cognitive
impairment in memory (aMCI) or other cognitive domains (naMCI), more accentuated
than in people of the same age and education with intact functional abilities and without
dementia. Focusing on the amnestic type, the following diagnostic criteria have been
suggested: (1) memory complaints, preferably corroborated by an informant; (2)
memory impairment documented according to appropriate reference values; (3)
essentially normal performance in non-memory cognitive domains; (4) generally
preserved activities of daily living; and (5) no dementia (e.g. Petersen, 2004).
Epidemiological studies have estimated that the prevalence of MCI in the elderly
population ranges from 3% to 19%, and that 11%-33% of people with MCI develop
dementia within two years (Gauthier et al., 2006). It is, therefore, a priority to develop
procedures that might help these individuals manage their memory problems, offer them
protection against cognitive decline, promote brain plasticity, and thereby attenuate the
risk of dementia. This is particularly crucial because there is currently no clear evidence
of any benefit of pharmacological treatment for MCI (e.g. Aisen, 2008).
Since memory problems appear to be the key feature for defining aMCI, increasing
numbers of studies are attempting to understand how effective cognitive interventions
may be for these patients, and most of this research has focused on episodic memory
performance. Although the results of single studies have generally appeared positive
(e.g. Belleville et al., 2006), two recent meta-analyses showed that the dimension of the
gains was generally in the medium effect size range (see Li et al., 2011), but
considerably lower in studies with an active control group (Zehdner et al., 2009). In fact,
50

the meta-analyses showed that, for most measures, the improvement seen in the
trained group was no larger than in the active control group, thus suggesting unspecific
gains. It is worth noting that these meta-analyses combined different types of
intervention (cognitive stimulation with cognitive training of various kinds, e.g. strategytaught, computer-based training, practicing with different neuropsychological tasks,
etc.), making it difficult to establish which program is most appropriate for MCI patients.
None of the studies focused on one of the basic mechanisms of cognition, however, i.e.
working memory (WM) capacity, the age-related decline of which is well documented
(e.g. Borella et al., 2008).
In the context of healthy aging, researchers are increasingly analyzing the feasibility of
improving WM capacity by testing the impact of WM training on cognitive processes
associated with or implicit in WM. This interest in WM stems from the fact that it is: (i)
one of the mechanisms most sensitive to aging; (ii) an early marker of AD (Rosen et al.,
2002); and (iii) associated with MCI (e.g. Missonnier et al., 2007). WM is also involved
in different complex skills relating to everyday life, so any benefits deriving from WM
training could have definite, positive consequences in improving an elderly person's
functioning and quality of life.
Outcomes of WM training recorded to date in normally aging elderly adults have
generally been positive: most studies have reported improvements in tasks practiced
directly during the training program (e.g. Busckhuel et al., 2008; Borella et al., 2010;
Carretti et al., 2012; Richmond et al., 2011). There have also been reports of transfer
effects on other tasks (identified by measuring mechanisms related to WM, such as
inhibition and processing speed), and on cognitive processes that involve WM, such as
fluid intelligence (Borella et al., 2010) or language comprehension (Carretti et al., 2012).
Both Borella et al. and Carretti et al. suggested much the same WM training procedure
for elderly adults (aged between 65 and 75 years), which consisted of practicing with a
verbal WM training task in which the level of difficulty was adaptive (if a participant
succeeded at a given level, the task was made more difficult; if not, the task was made
easier), and the requirements of the trained task also changed constantly. According to
both authors, such a procedure facilitated a positive outcome of the training by involving
multiple processes (encoding, maintenance of information, inhibition of no-longer
relevant information, simultaneous management of two tasks, shifting attention, and
ability to control attention) and stimulating a flexible approach to the task. The
improvement obtained in WM performance and its transfer to other cognitive processes
confirmed that the elderly preserve some degree of plasticity, despite the general
decline in their cognitive resources, and, as Borella et al. suggested (2010), this may
indicate that the training enabled the building of scaffolds to compensate for age-related
decline (Park and Reuter-Lorenz, 2009).
In the light of previous studies, we expected WM capacity to be plastic even in
individuals with aMCI, and we consequently predicted that the trained participants would
experience an improvement in their performance in the trained WM task, while controls
would not. Limited transfer effects were expected, however, based on the abovementioned studies (and the meta-analyses in particular).
51

Method
Participants
Twenty participants from 65 to 75 years old with aMCI were recruited from memory
clinics in Brescia, Italy. They were selected on the basis of a clinical and
neuropsychological evaluation. The diagnosis of aMCI was reached according to the
following exclusion criteria proposed by Petersen and colleagues (Petersen et al., 1999;
Petersen, 2004) including: exclusion criteria for dementia; a performance of at least 1.5
standard deviations (SD) below the norm for age and education on measures assessing
episodic memory, measured with the Story Recall test (Spinnler and Tognoni, 1987), in
which participants have to recall a story both immediately and after a delay; no evidence
of any deficit in executive function, measured with the Trail Making tests A and B
(Reitan, 1958), or language (measured with semantic and phonemic fluency tests
(Benton and Hamsher, 1983)), or visuospatial ability (measured with Rey's figure copy
(Osterrieth, 1944)); a score above the cut-off of 24/30 in the Mini-Mental State
Examination (MMSE) (Folstein et al., 1975); a score of 0.5 in the Clinical Dementia
Rating (CDR) (Hughes et al., 1982); no evidence of difficulties in everyday abilities, as
measured on the Basic Activities of Daily Living scale (BADL) (Katz et al., 1970) and
Instrumental Activities of Daily Living scale (IADL) (Lawton and Brody, 1969); no
depression, as measured on the Geriatric Depression Scale (GDS, 15 items) (Sheikh
and Yvesavage, 1986); and no evidence of metabolic, endocrine, or nutritional
deficiencies.
All participants lived at home. They gave their informed written consent prior to the
commencement of the study and they received no financial compensation for their
participation. The study was approved by the ethical board of the Faculty of Psychology,
Padua University, Italy.
Ten participants were randomly assigned to the experimental group (6 males and 4
females) and the other ten to the control group (4 males and 6 females). The two
groups did not differ in terms of age or education (see Table 1). As it is possible to see
from Table 1, the average educational level of the sample considered was fairly low
compared to other studies. It should be noted, however, that compulsory education
spanning eight years was only introduced definitively in Italy in 1962. Beforehand, it was
not unusual for people to finish their formal education with primary school. As a
consequence, there are still people between 65 and 75 years old with only five years of
schooling. On the other hand, as Stigsdotter-Neely and Bckman (1995) pointed out,
educational level seems to be unrelated to training outcomes, in normal aging at least.
Table 1.
Demographic characteristics of the trained and the control groups
trained group

control group
52

n = 10

n = 10

sd

sd

t(18)

Age

71.8

2.20

70.6

2.63

1.106

ns

Years of education

6.50

2.83

7.20

3.29

-0.509

ns

MMSE

27.20

1.68

27.10

1.19

0.153

ns

CDR*

0.5

0.5

Immediate

2.73

0.86

2.86

0.60

-0.600

ns

Delayed

2.32

0.81

2.53

0.99

-0.249

ns

TMT A (sec)

59.5

14.79

53.60

13.07

0.945

ns

TMT B (sec)

146.90

32.41

130.30

35.06

1.099

ns

Semantic fluency

32.1

2.80

33.90

3.07

-0.538

ns

Phonemic fluency

27.7

3.23

28.4

2.54

-1.368

ns

Rey's copy

34.30

2.14

35.35

2.08

-1.109

ns

Story recall

53

BADL (functions lost)

IADL (functions lost)

0.2

0.42

0.1

0.31

0.600

ns

GDS (15 items)

2.2

1.81

1.7

1.88

0.604

ns

*t value was not computed since standard deviations were equal to zero. Note: MMSE:
Mini-Mental State Examination; CDR: Clinical Dementia Rating; TMT: Trail Making test;
BADL: Basic Activities of Daily Living scale; IADL: Instrumental Activities of Daily Living
scale; GDS: Geriatric Depression Scale.
Material
The same tasks were used as in the study conducted by Borella et al. (2010).
Verbal WM: Categorization Working Memory Span test (CWMS, De Beni et al., 2008;
see Borella et al., 2010). The task consisted of 20 lists of words, which were organized
into a set of word lists of different lengths (from two to six). Each list contained five
words of high-medium frequency. Participants listened to the set of lists of audiorecorded words presented at a rate of 1 sec per word and had to tap with their hand on
the table whenever they heard an animal noun (processing phase). The interval
between the word lists was 2 sec. At the end of the set, participants recalled the last
word of each list in consecutive order (maintenance phase), so they needed to
remember from two to six words, depending on the set's difficulty level. Two practice
trials consisting of two-word lists (and requiring the recall of two words) were
administered before the experiment started. The total number of correctly recalled
words was used as the measure of WM performance (maximum score 20). Cronbach's
[alpha] was 0.98 (from De Beni et al., 2008).
Transfer effects
Visuospatial WM task: Dot matrix task (adapted from Miyake et al., 2001). This task
involves participants verifying a matrix equation, consisting of an addition or a
subtraction presented as lines drawn on a 3 3 matrix, and then memorizing
sequences of dots presented on a 5 5 grid. Participants were given a maximum of 4.5
sec to verify each equation and say "True" or "False." Immediately after they gave each
answer, they were shown a 5 5 grid containing a dot in one of its squares for 3 sec
and then had to recall the position of the dot in an empty grid. There was one practice
54

trial with two equations, each with one dot. The number of dot locations to recall
increased from two to six.
Long-term memory: List recall (from Carretti et al., 2007). Two lists of 15 words of
comparable length and imagery value were prepared. Participants heard the list of
audio-taped words presented at a rate of 2 sec per word. At the end of the presentation,
they were asked to recall as many items on the list as possible, in any order. The final
score corresponded to the total number of words recalled correctly. Pre- and post-test
word lists contained different words. The test-retest reliability was 0.87 (from the dataset
in Carretti et al., 2007).
Fluid intelligence: Culture Fair Test, scale 3 (Cattell and Cattell, 1963). Scale 3 of the
Cattell test consists of two parallel forms (A and B), each containing four subtests to be
completed in 2.5-4 minutes, depending on the subtest. The subtest requires that
participants: (1) complete an incomplete series of figures, choosing which of six options
best completes the series; (2) identify figures or shapes that differ from the others; (3)
choose items that correctly complete matrices of abstract figures and shapes; and (4)
assess the relationship linking a series of items. The dependent variable considered
was the number of items answered correctly across the four subsets (maximum score
50). Cronbach's [alpha] was 0.63 (from Cattell and Cattell, 1963).
For each task, parallel versions were used at the pre- and post-test points,
counterbalanced across testing sessions.
Note: CWMS: Categorisation Working Memory Span test.
The WM training consisted of three sessions (sessions 2, 3, and 4), each lasting about
30-40 minutes. During the training sessions, the experimenter presented this group of
participants with lists of words, audio-recorded and organized in the same way as for
the CWMS task. Participants were asked to recall target words and always tap on the
table with their hand when an animal noun arose. Some manipulations were introduced
during the three sessions, however, to facilitate a generalized transfer and contain the
development of task-specific strategies. The maintenance demand of the CWMS task
was manipulated by increasing the number of words successful participants were asked
to recall, and by presenting the lowest
Results
Pre-test performance between the two groups was compared first. T-test results
showed no significant difference between the groups.
Given the small sample size, a benefit index was calculated for each measure, i.e. posttest performance minus pre-test performance, to identify any benefits of the training
(see Buschkuehl et al., 2008; Zincke et al., 2012); this also enabled us to control for
slight variations in pre-test performance. T-tests were then run on the indexes to

55

compare groups (the results did not change when non-parametric statistics were used).
Descriptive data, along with the pre- to post-test gains, are given in Table 3.
Table 3.
Descriptive data for pre-test and post-test by group
trained
group

control group

pre-test

postpre- postgains
gains
test
test test

sd

CWMS

6.80

1.39 10.60 1.95 3.8

1.62 7.40

2.27 7.90

3.14 0.50 2.22

Dot matrix 5.60

2.45 7.90 0.99 2.3

2.58 6.70

2.45 7.30

2.05 0.60 2.91

Forward
digit span

5.40

1.77 5.2

1.68 -0.20 1.23 5.10

1.44 5.50

1.08 0.40 1.07

Backward
digit span

4.00

1.63 4.70 1.05 0.70 1.41 3.60

0.84 4.30

1.16 0.70 0.95

List recall

3.00

1.15 4.40 0.96 1.40 1.58 3.30

1.76 3.60

1.77 0.03 0.95

sd

sd

sd

sd

sd

Pattern
comparison 153.5 42.4 163.6 55.97 10.10 31.40 142.70 43.60 141.60 27.75 -1.1 23.59
(times)
Intrusion
errors
(CWMS)*

0.36

0.27 0.16 0.13 -0.80 1.23 0.41

0.49 0.33

0.32

2.01
0.50

56

Cattell test 13.70 4.76 17.40 4.47 3.70 4.64 14.30 4.21 13.90 3.69

3.09
0.40

*a negative value indicates a decrease in intrusion errors.

Criterion task: CWMS
The benefit index (the improvement from the pre-test to the post-test assessment) was
higher for the trained group than for the control group, t(18) = 3.79, p < 0.001.
Transfer effects
Dot matrix. There were no differences in the benefit index between the groups.
Forward and Backward Digit Span. There were no differences in the benefit index.
List recall. There was a tendency for trained participants to experience a greater benefit
than the control group, t(18) = 1.89, p = 0.079.
CWMS intrusions. The main effect of group was not significant when the proportion of
intrusion errors in CWMS was considered.
Figure 1.
Cohen's d for the trained and the control groups.
To further document the magnitude of the training-related gains in terms of individual
differences within each group, all participants were divided into two groups, i.e. (a)
those whose performance improved by 1 SD or more with respect to the mean pre-test
performance of the participants as a whole, and (b) those whose gain improved by less
than 1 SD.
The results are given in Figure 2 and show that, for the CWMS task, the percentage of
participants whose performance improved was 90% in the trained group and 30% in the
control group (Cramer's V = 0.725, p < 0.01). When the Dot matrix task was taken into
account, 60% of participants in the trained group improved in performance, as opposed
to 10% in the control group (Cramer's V = 0.524, p < 0.05). In the Cattell test, 60% of
the trained participants improved from the pre- to the post-test situations, while none of
the controls did so (Cramer's V = 0.655, p < 0.01). Finally, in the List recall task, 50% of
the trained participants and only 10% of the controls improved from the pre- to the posttest assessments (Cramer's V = 0.436, p = 0.05).
Discussion and conclusion

57

Memory deficits are typical of aMCI, with shortcomings particularly in episodic memory.
Some recent studies have nonetheless suggested that impairments in other memory
functions, such as WM, are a common feature of MCI (Saunders and Summers, 2011).
It therefore seems crucial, from both the practical and the theoretical points of view, to
understand whether WM training can positively affect cognitive performance in aMCI.
This is particularly relevant when we consider the crucial role of WM in everyday
activities (such as problem-solving and reading comprehension), and how progression
to dementia gradually interferes with independent life.
When the dimensions of the effects were considered, they were in the range of a
medium effect size according to Cohen's guidelines (1988). When the present results
were compared with those obtained by Borella et al. (2010) in healthy young-old people,
the dimension of the effect for the criterion task was nearly the same (d = 2.25 for
healthy young-old). However, the transfer effects in our participants were less broad and
less robust than those obtained in Borella's healthy young-old sample (Dot matrix: d =
1.7; Cattell: d = 1.40 for healthy young-old).
These findings suggest that our training procedure - involving tasks that were always
challenging because their difficulty and the type of processing required were constantly
manipulated - enabled different cognitive processes to be targeted and a consequently
better management of the participants' cognitive resources, promoting their encoding
and maintenance of information, and possibly stimulating plasticity as a result (Borella
et al., 2010). All these mechanisms are fundamental not only to the memory domain but
also in other aspects of cognition requiring the control of attentional resources. This
latter aspect seems to be particularly relevant in the light of the results of the
longitudinal study by Saunders and Summers (2011), who reported a specific decline
also in non-memory functions relating to executive control (i.e. divided attention tasks)
in cases of aMCI.
To conclude, the results reported here suggest that WM training could be a valuable
method for supporting cognitive flexibility in cases of aMCI, potentially containing the
progression of their disease. Indeed, we found a transfer to some of the cognitive
components of memory that are part of the core cognitive impairment responsible for
the degeneration of MCI into AD. In this regard, the main limit of the present study
relates to the small sample size, which means that it can only be considered as a pilot
study. Follow-up studies on the WM training in aMCI should include larger numbers of
participants. The efficacy of the program considered here should also be tested on
better-educated older adults to see if this variable, which is considered a protective
factor and correlates with cognitive reserve (Chicherio et al., 2012), might favor larger
transfer effects. Some studies suggest, however, that level of education is unrelated to
training outcomes (e.g. Stigsdotter-Neely and Bckman, 1995). It would also be useful
to include non-cognitive measures, and to assess their role in explaining the efficacy of
the present training. The activities conducted with our control group (filling in
questionnaires on memory failures and strategies to prevent them) may have
exacerbated their anxiety, given that they already had memory difficulties. We had the
impression that this was not the case, however, since the controls reported appreciating
58

the opportunity to discuss some of the problems they encountered in daily life during the
informal interview at the end of the training sessions.
Finally, future studies should also include follow-up sessions to ascertain any
maintenance effects, and the rate of conversion in AD too (which was not considered in
the present study). Because this was the first study (to our knowledge) to propose WM
training, our aim was initially to establish whether this was feasible in cases of aMCI,
and whether it produced any transfer effects on other cognitive measures. Now that
these goals have been achieved, future studies will try to replicate the present approach
and also including follow-up sessions and more ecological measures.

SUMMARY
A growing number of studies are attempting to understand how effective
cognitive interventions may be for patients with amnestic mild cognitive impairment
(aMCI), particularly in relation to their memory problems. Methods: The present study
aimed to explore the benefits of a working memory (WM) training program in aMCI
patients. Patients were randomly assigned to two training programs: the experimental
group practiced with a verbal WM task, while the active control group conducted
educational activities on memory. Results showed that the aMCI patients completing the
WM training obtained specific gains in the task trained with some transfer effects on
other WM measures (visuospatial WM) and on processes involved in or related to WM,
e.g. fluid intelligence (the Cattell test) and long-term memory. This was not the case for
the aMCI control group, who experienced only a very limited improvement. Conclusion:
This pilot study suggests that WM training could be a valuable method for improving
cognitive performance in aMCI patients, possibly delaying the onset of Alzheimer's
disease.

REACTION
Mild cognitive impairement causes cognitive changes that are serious enough to
be noticed by the individuals experiencing them or to other people, but the changes are
not severe enough to interfere with daily life or independent function. However in
Amnestic Mild Cognitive Impairment, there is the preface of amnestic therefore it would
imply that memory loss is part of the cognitive impairment in which it is in a whole
different scale. The article talks about the effective cognitive interventions that maybe
for patients with amnestic mild cognitive impairment, particularly in relation to memory
problems which is the main problem of amnestic disorder. The article states the
methods of working memory (WM) training program in which the experimental group
practices the verbal WM task while the control group conducted educational activities on
59

memory. The WM consisted of three sessions, each lasting about 30-40 minutes. During
the training sessions, the experimenter presented this group of participants with losts of
words, audio-recorded and organized in the same way for the CWMS task. The
participants were asked to recall target words and always tap on the table with their
hand when an animal noun arose and basically each session they were given more
words. In the control groups side, they were involved in an education program aiming to
reflect on how memory works, presenting the different memory systems, focusing on
everyday memory failures, and on the importance of external and internal strategies for
supporting memory. In the long run the article supported that constant practice of
memory and learning could help stimulate the brain more than just learning theories and
facts. Hence, in our nursing class we do not only have lectures in a day by day basis but
we also have our RLE in order for us nurses to use the knowledge we gain. It is not
enough that we learn about concepts and theories; we must put it into use and practice
it daily. There is still hope for people with amnestic mild cognitive impairment, if only we
would exercise our neurons and stimulate them to bring them back prior to the day of
impairment.

60

VIII.

BIBLIOGRAPHY

Cox, H. (2007). Cox's clinical applications of nursing diagnosis adult, child, women's,
mental health, gerontic, and home health considerations. F.A. Davis Co.
Doenges, M., Moorhouse, M., & et al. (2010). Nurse's pocket guide diagnoses,
interventions, and rationales. 12th ed. Philadelphia. F.A. Davis

MedicineNet. HALOPERIDOL - ORAL (Haldol) side effects, medical uses, and drug
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Retrieved

from:

http://www.medicinenet.com/haloperidol-

oral/page2.htm
MedicineNet. DONEPEZIL - ORAL (Aricept) side effects, medical uses, and drug
interactions. Retrieved from: http://www.medicinenet.com/donepeziloral/page3.htm
Mavrodaris, A., Powell, J. & Thorogood M.. (2013). Prevalences of dementia and
cognitive impairment among older people in sub-Saharan Africa: a systematic
review. In Bulletin of World Health Organization. Retrieved March 20, 2015, from
http://www.who.int/bulletin/volumes/91/10/13-118422/en/.

n.a. (2003). Cognitive disorders. In Learning Rx. Retrieved March 20, 2015, from
http://www.learningrx.com/cognitive-disorders-faq.htm.

61

IX.

APPENDICES

Alcantara Nursing Care Plans

Ang Types, Etiology, Clinical Manifestations, Diagnostic Characteristics
Arancon Types, Etiology, Clinical Manifestations, Diagnostic Characteristics
Daral Types, Etiology, Clinical Manifestations, Diagnostic Characteristics
Chan Pharmacologic
Cubil Nursing Care Plans
Maturan Brief Introduction, Formatting, Proofreading, Compilation
Monsanto Psychotherapies
Nasol Journal Readings
Tan Journal Readings

62