Cognitive and

Neurologic Function

The nervous system is a network of complex structures that undergo

many neurophysiologic changes with aging. Some changes that occur in the brain
do not affect all older individuals equally, and the individual presentation of
neurologic changes varies from person to person. An individual’s lifestyle, nutritional
intake, genetic makeup, and tissue perfusion are some of the many factors that
affect the neurologic system.
Structural Age-Related
Changes of Neurologic
System
NEUROLOGIC COMPONENTS IN THE CENTRAL NERVOUS SYSTEM
1. Neurons
Shrinkage in neuron size and gradual decrease in neuron numbers
Structural changes in dendrites
Deposit of lipofuscin granules, neuritic plaque, and neurofibrillary bodies within cytoplasm and neurons
Loss of myelin and decreased conduction in some nerves, especially peripheral nerves
2. Neurotransmitters
Changes in precursors necessary for neurotransmitter synthesis
Change in receptor sites
Alteration in enzymes that synthesize and degrade neurotransmitters
Significant decreases in neurotransmitters, including ACh, glutamate, serotonin, dopamine, and gamma-aminobutyric acid

NEUROLOGIC COMPONENTS IN THE PERIPHERAL NERVOUS SYSTEM

1. Motor
Muscular atrophy—decrease in muscle bulk
Decrease in the electrical conduction system
2. Sensory
Atrophy of taste buds
Alteration in olfactory nerve fibers
Alteration in nerve cells of the vestibular system of inner ear, cerebellum, and proprioception
3. Reflexes
Altered electrical conduction of the nerve caused by myelin loss
Altered reflex responses (ankle, superficial reflexes)
4. Reflexes
Physiologic changes in the RAS results in a decrease in stages 3 and 4 of the sleep cycle

NEUROLOGIC COMPONENTS IN THE AUTONOMIC NERVOUS SYSTEM

1. Basal ganglia
Slowing of autonomic nervous system response as a result of structural changes in basal ganglia
NEUROGLIA AND SCHWANN CELLS
Aging Schwann cells exhibit reduced myelin clearance, it would be of great interest to understand whether
myelinophagy mechanisms are also altered with aging.

CEREBROSPINAL FLUID AND VENTRICULAR SYSTEM

As people get older, the volume of the ventricles (the spaces in the brain that contain cerebrospinal fluid) increases. It is
thought that this enlargement occurs because cells surrounding the ventricles are lost.

HIPPOCAMPUS AND THE HYPOTHALAMIC-PITUITARY-ADRENAL AXIS

Normal aging is associated with changes in the ability to consciously learn and retain new information easily. This occurs
as a result of structural changes, synapse loss in the neurons, decreased microvascular integrity, reduction in glucose
metabolism, and alterations in the neuroglia cells with aging.
As a result of changes in the secretory pattern of the hypothalamic-pituitary–adrenal (HPA) axis, additional alterations
occur in the hippocampal area of the brain

CEREBROSPINAL FLUID
A reduction in the turnover of CSF with age decreases the distribution and efficiency with which the necessary substances are delivered from the
CP to the brain target sites.
One significant factor that reduces the turnover secretion rate of CSF is the age-related increase in resistance from the vascular (sagittal venous
sinus) system in the arachnoid.

RETICULAR FORMATION AND SLEEP PATTERNS

Rapid eye movement (REM) sleep- This is the stage of sleep during which muscle tone decreases significantly. In advanced aging REM sleep is
maintained without much decline.
Non-REM sleep- This is subdivided into four stages. Stages 1 and 2 constitute light sleep, and stages 3 and 4 are deep sleep or slow-wave sleep.

With aging, the duration of stage 1 sleep and the number of shifts into stage 1 sleep increase. Stages 3 and 4 decrease significantly with aging. Among
the oldest-old people (older than 90 years), stages 3 and 4 may disappear completely. Some older women have normal or even increased stage 3 sleep,
whereas men have normal or reduced stage 3 sleep.
 Assessment of
Cognitive Function
SELECTED COGNITIVE FUNCTION SCREENING INSTRUMENTS FUNCTIONAL ASSESSMENTS
1. Dementia Severity Rating Scale- an 11-item instrument that can be easily and quickly administered
and covers memory, orientation, judgment, community affairs, home activities, personal care, speech
and language recognition, feeding, incontinence, and mobility or walking

2. Mental status examination

Mini-Cog- a 3-minute test that is used to screen for cognitive impairment in older adults.
Blessed Dementia Scale- another frequently used screening tool for the assessment of dementia.
BOMC test- consists of six questions and is used by many disciplines.

3. Depression Assessment- Depression frequently occurs alongside major conditions such as heart disease, stroke, diabetes,
cancer, and Parkinson's (PD). Many older adults face these illnesses and health care workers may wrongly think that
depression is a typical result of these conditions, an opinion often shared by patients.

COGNITIVE FUNCTION AND MEMORY IN TYPICAL AGING

The idea that aging causes forgetfulness has shaped society's attitudes on aging. Impaired cognition results in changes in
mental status as well as cognitive performance, such as the inability to spell ordinary words, compute simple sums, balance a
checkbook or drive safely.
 Cognitive Disorders
Associated with Altered
Thought Processes
DEPRESSION
- As an individual age, the rate of depression increases. The estimate is 20% to 25% of those older
than 55 have evidence of a mental health disorder. These include anxiety, depression, dysthymic
disorder, and severe cognitive disorders.

CLINICAL MANIFESTATION
Constipation
Psychomotor retardation
Depressed mood
Loss of interest, energy, libido, or pleasure
Changes in appetite, weight, and sleep patterns
Agitatio
Anxiety
Crying

DELIRIUM
- Delirium is characterized by a loss of capacity to focus, sustain, or shift attention.
Cognitive (mismemory, disorientation, speech) or perceptual changes (disturbances) are separate
from preexisting or emerging dementia. The onset is quick (hours to days) and fluctuates
throughout the day.

RISK FACTORS
Advanced age, CNS diseases, Infection, Polypharmacy, Hypoalbuminemia, Electrolyte imbalances,
Trauma history, Gastrointestinal or genitourinary disorders, Cardiopulmonary disorders, Sensory changes
CLINICAL MANIFESTATION
Clouding of consciousness or fluctuation of awareness
Misperceptions, illusions, or hallucinations
Disorientation to persons, place, and time
Memory problems
Increased or decreased physical activity
Impaired judgment

MANAGEMENT
Non-pharmacologic interventions- A therapeutic environment would include frequent reassurance and
reality orientation; clear communication; caregiver consistency; decreased; decreased stress and anxiety
through frequent reassurance and providing daily routine; maintaining comfort; reestablishing sleep-wake
cycle; ensuring adequate daily fluid intake;; providing for physical activity, ambulation, and range of motion;
and avoiding chemical or physical restraint.
Medication should be used as a last resort
DEMENTIA
Syndrome of gradual and progressive cognitive decline.
It has been defined as an alteration in memory, in addition to acquired persistent alteration
in intellectual function compromising multiple cognitive domains.

REVERSIBLE DEMENTIA
A phenomenon that occurs when other pathologic conditions masquerade as dementia
Causes:
- Medications
- Ethyl alcohol (ETOH) intoxication or withdrawal
- Metabolic disorders:
- Thyroid disease
- Vitamin B12 deficiency
- Hyponatremia
- Hypercalcemia
- Hepatic dysfunction
- Renal dysfunction
- Depression
- Delirium
- Neoplasia of the central nervous system
- Chronic subdural hematoma
- Normal pressure hydrocephalus
ALZHEIMER DISEASE
- A progressive, neurodegenerative disease characterized by the presence of neurofibrillary tangles
composed of misplaced proteins within the brain, cortical amyloid plaques, and granulovascular
degeneration of neurons in the pyramidal cell layer of the hippocampus.

RISK FACTORS:
Research has focused on genetic, nutritional, viral, environmental, and other causes of AD.
Age is the single most important risk factor for the development of AD, as the number of people
with the disease doubles every 5 years beyond age 65

CLINICAL MANIFESTATION
Repeating questions and statements, pervasive forgetfulness and memory loss, language deterioration, impaired ability to
mentally manipulate visual information, poor judgment, confusion, restlessness, and mood swings.

DIAGNOSTIC STUDIES:
Magnetic resonance imaging (MRI) and computed tomography (CT) are used in the medical workup mainly to rule out any
other brain conditions and have been used to identify the hippocampal atrophy associated with the diagnosis of AD.
TREATMENT
Tacrine (Cognex) was the first of the cholinesterase inhibitors, but because of the need to
frequently monitor a patient liver function, its use is limited.
Namenda (memantine) is used to treat moderate to severe AD, and its main effect is to delay
the progression of some of the symptoms.

NURSING MANAGEMENT
Previously the management of patients with dementia consisted of helping patients and their
families through progression of the disorder while allowing them as much dignity and
independence as possible.
The focus is now on maintaining cognitive and global functioning early in the disease process to
postpone the need for institutional care.

Vascular Dementia
The second most frequently occurring type of dementia among older persons, causing dementia in 20% to 30% of people. It
is defined as a loss of cognitive function resulting from ischemic, hypoperfusive, or hemorrhagic brain lesions resulting from
cerebrovascular disease or cardiovascular pathologic conditions.

RISK FACTORS
Ateriosclerosis, blood dyscrasias, cardiac decompensation, hypertension, atrial fibrillation, cardiac valve replacements,
systemic emboli for other reasons, diabetes mellitus, peripheral vascular disease, obesity, and smoking.
CLINICAL MANIFESTATION
Gradual-onset VaD occurs as a result of small lacunar infarcts that affect a very small area of the
brain, causing memory, motor, or sensory perceptual function deficits.

DIAGNOSTIC STUDIES:
Neuroimaging with either CT or MRI usually reveals one or more areas of cerebral infarction.
Other than neuroimaging and clinical examination

TREATMENT:
Treatment for VaD is the same as for AD.

LEWY BODY DEMENTIA

A progressive, degenerative brain disorder causing decline in thinking, reasoning, and independent functioning caused by
abnormal small deposits in the brain matter.

RISK FACTOR:
No risk factors or causes are known for DLB at this time

CLINICAL MANIFESTATION:
The clinical manifestations of DLB are similar to those of AD; however, DLB is often marked by prominent fluctuations in attention
and ability to communicate and by the severity of psychiatric symptoms, particularly visual hallucinations.
OTHER SYMPTOMS:
Excessive daytime sleepiness and altered arousal
Periods of reduced attention and concentration
REM sleep disorder

DIAGNOSTIC STUDIES:
Diagnosis is based on the health care professional’s best judgment following neurologic examination
and tests

MANAGEMENT:
Management of patients with DLB focuses on symptomatic relief when psychiatric and behavioral
symptoms become distressing.
The use of cholinesterase inhibitors has been supported in DLB, as is the use of antidepressants, especially the use of selective
serotonin reuptake inhibitors
Antipsychotic drugs should be used with extreme caution as these may cause serious side effects in around 50% of patients
Since these patients also have sleep disorders involving REM sleep, clonazepam may be used.

FRONTOTEMPORAL DEMENTIA
A clinical syndrome of exclusion associated with non-AD pathologic conditions and is relatively rare in the clinical setting.

RISK FACTORS:
The risk factors for FTD are poorly understood.
CLINICAL MANIFESTATION:
FTDs are defined generally by the earliest symptoms:
(1) progressive behavior and personality decline with a change in personality, emotions, behavior and
judgment, called behavioral variant frontotemporal dementia or Pick disease;
(2) progressive language decline, with early changes in language ability in speaking, reading, writing
and understanding, called primary progressive aphasia;
(3) progressive motor decline, characterized by difficulties with physical movement, including shaking,
difficulty walking, frequent falls, and poor coordination

DIAGNOSTIC STUDIES:
Neuroimaging with CT or MRI may be useful in the diagnosis of FTD
Positron emission tomography (PET) or single photon emission computed tomography (SPECT) may also assist in
the confirmation of the clinical diagnosis.

MANAGEMENT:
Currently, no treatments for FTD are available, but patients with FTD do benefit from a team approach with the use of speech
therapists, physical therapists, day care, respite care, and the judicious use of medications to control symptoms.
OTHER DEMENTIA-RELATED DISEASES NORMAL:

PRESSURE HYDROCEPHALUS
Rare but potentially reversible condition; if left untreated, it leads to permanent cognitive impairment.
NPH has a triad of symptoms that present together:
(1) gait disturbance (e.g., ataxic or magnetic gait),
(2) urinary incontinence
(3) cognitive dysfunction

SUBDURAL HEMATOMAS
Older adults are at risk for the development of subdural hematomas caused by brain atrophy and
corresponding vascular changes that occur with normal aging and are also at risk for falls and subsequent
head injuries.

Two types of subdural hematomas:

Symptoms of acute subdural hematomas develop within 48 to 72 hours after a head injury but are not seen with the typical signs of
increased intracranial pressure (ICP). Instead, the presentation includes insidious changes in mentation and focal neurologic signs.
Chronic subdural hematomas may be caused by trauma but often are not noticed until 3 or more weeks after the initial injury because
of slow bleeding into the intracranial space.

INTRACRANIAL TUMORS
Intracranial tumors in older adults rarely are seen with the typical signs of increased ICP (e.g., headaches, vomiting, and papilledema);
rather, they are seen with subtly progressive changes such as withdrawal, isolation, personality changes, and slowly progressive
hemiparesis. Because the symptoms are insidious and include cognitive dysfunction and withdrawal, older adults with intracranial
tumors are often misdiagnosed with depression or dementia; later, when focal neurologic signs appear, brain tumors are considered.

AMNESIC DISORDERS
Memory impairment is the result of a general medical condition or the persisting effects of a drug, medication, or toxin.
Diagnostic Assessment
of Altered Thought
Processes
EXAMINATION
History taking, physical examination, behavioral observation, and functional and mental status
examinations form the basis for a diagnosis of depression, delirium, and dementia.

DIAGNOSTIC STUDIES
CT, MRI, and electroencephalography (EEG) have been used for diagnosis of delirium or dementia.
CT is useful in detecting pathologic conditions such as space-occupying lesions (e.g., intracranial tumors,
subdural hematomas, and hydrocephalus) that may lead to dementia.
MRI is useful in the diagnosis of VaD
EEG may provide important information about the mental status.
PET is a non-invasive technique that allows assessment of regional glucose use, oxygen consumption, and regional cerebral blood
flow. This technique may be useful in the differential diagnosis of the hippocampal atrophy seen in AD and the changes
associated with FTD.

LABORATORY STUDIES
Laboratory screening tests
Genetic testing
Postmortem biopsy
Treatment of Altered
Thought Processes
PHARMACOTHERAPY DISEASE MANAGEMENT
Depression requires the use of antidepressant medications
Medication withdrawal or augmentation to treat underlying problems may be used to treat delirium.
Cholinesterase inhibitors have shown some promise in the treatment of both VaD and DLB

BEHAVIOR MANAGEMENT
Antipsychotics, antidepressants, benzodiazepines, buspirone (BuSpar), and antiepileptics are available
to aid in the behavior management of older persons with dementia.
Antipsychotics are useful for the treatment of the behavioral response to psychotic symptoms
such as delusions or hallucinations.
´Haloperidol in daily doses of 0.25 to 2 milligrams (mg) orally or intramuscularly has been
supported for acute control of agitation symptoms

DEPRESSION MANAGEMENT
Antidepressants
Taking a sedating antidepressant like Trazodone at night can help soothe. It is commonly prescribed for mild to moderate
agitation in older adults during the day.
SSRIs such as paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac) have been helpful in managing agitation.

´BENZODIAZEPINES
Used for acute situations- lorazepam (Ativan), 0.25 to 1 mg orally or intramuscularly, or oxazepam (Serax), 5 to 10 mg orally.

´BUSPIRONE
The treatment of anxiety triggered agitation.
ANTIEPILEPTIC OR ANTICONVULSANT MEDICATIONS

Valproic acid is used most frequently as mood stabilizer.

Carbamazepine has an antikindling effect on CNS electrical activity at serum levels between 4 and
8 micrograms per milliliter (mcg/mL). Unfortunately, multiple drug interactions and potentially
serious side effects such as agranulocytosis, ataxia, and hyponatremia limit the use of carbamazepine.
Divalproex has fewer side effects and drug interactions, making it more likely to be the first-line agent for
the treatment of moderate to severe agitation and combativeness among older adults.

NURSING MANAGEMENT
Perform a complete baseline physical examination, along with neurologic examination, mental
status assessment, level of consciousness, assessment of depression, pupil assessment, and behavioral
assessment
When caring for dementia patients, basic and direct therapeutic verbal and nonverbal communication is vital.
Behavioral approaches should be used first for older persons with cognitive deficits.
Support the family members of the person with cognitive difficulties.
Challenges In The Care
Of Older Adults With
Cognitive Disorders
SUNDOWN SYNDROME
Along with depleted cognition, other symptoms such as reduced attention, altered sleeping and waking
patterns, and disturbed psychomotor behavior are present, and these symptoms tend to be more evident
in the evening.
Specific pathophysiologic findings that relate to sundown syndrome behaviors include disturbance in
REM sleep, episodes of sleep apnea, and deterioration of the suprachiasmatic nucleus of the hypothalamus.
The first step in the management of sundowning behavior includes the identification and treatment
of any physiologic factors that may be contributing to those behaviors. These may include hunger,
thirst, pain, and elimination needs.

NONPHARMACOLOGIC MANAGEMENT STRATEGIES

Reducing environmental stimulation as the day progresses
Providing activities that are calming in the evening, for example, playing soft music
Providing 1-hour rest periods in either the late morning or the early afternoon
- Medication management of these behaviors should be avoided unless the older person is a danger to self or others. If nonpharmacologic
interventions are unsuccessful, low doses of specific neuroleptic agents may be indicated.

WANDERING
One of the most challenging behaviors to manage in older persons with cognitive impairments.
Wanderers might have experienced sleep problems, had a more active lifestyle in their younger years, and used more psychotropic
medications within their lifetime.

NONPHARMACOLOGIC INTERVENTIONS
Ensuring an environment safe for wandering
Informing neighbors and police of this potential problem
Having the person wear a medical alert bracelet
Observing potential wandering trigger behaviors
Maintaining a regular activity and exercise program for individuals prone to wandering behavior
PARANOIA OR SUSPICIOUSNESS
It may reflect an individual’s basic insecurity about his or her progressive memory and sensory losses.
Individuals with dementia may forget where they placed certain items and then become suspicious of
others and accuse them of stealing those items.

NONPHARMACOLOGIC INTERVENTION
Securing valuables in locked locations
Avoiding the use of confrontation and the application of logic
Looking in wastebaskets before emptying
Not whispering or behaving in a secretive manner
Marking all personal items with that individual’s name

HALLUCINATIONS AND DELUSIONS

Hallucinations experienced by individuals with dementia are most often visual but may be auditory. Reasoning or logic
is ineffective.
Delusions occur when an individual believes something to be true when it is illogical or wrong.

CATASTROPHIC REACTIONS
An emotional outburst or exaggerated reactions to minor stresses.
These may be precipitated by emotional and sensory overload and aggravated by fatigue, overstimulation, inability to meet expectations
or misinterpretation of actions or words.

NONPHARMACOLOGIC INTERVENTION
Removing the individual from the environment in which the reaction is occurring
Providing a calming atmosphere to distract the individual
Using a calm tone of voice, touch, and reassurance
Temporarily separating the individual from the causative source
 Other Common
Problems and Conditions
SUICIDE
One of the leading causes of suicide among older adults is depression, often undiagnosed and untreated.
Benign suicides or rational suicides refer to suicides planned by individuals because they perceive their life to
have no value.
Passive suicide or subintentioned suicide is a passive attempt to hasten one’s death. This type of
self-destructive behavior often goes unrecognized and may include noncompliance with the health care
regimen, behaviors that harm the individual in a more active manner, and participating in dangerous situations.

PLANNING AND EXPECTED OUTCOMES

1. The patient identifies and verbalizes thoughts and feelings related to his or her emotional state.
2. The patient reports an absence of suicidal ideation.
3. The patient demonstrates effective coping skills for managing stress and frustration, as evidenced by the reported use
of two coping strategies.
4. The patient experiences behavior control with the assistance of others, as evidenced by the absence of suicidal ideation.
5. The patient expresses satisfaction with spiritual well-being, as evidenced by verbalization of positive statements about self and life,
including a sense of purpose in life.

INTERVENTION
Safety measures may be tailored on the basis of the patient’s suicide plans. Developing a plan for safety.
Asking patients about their suicidal thoughts does not plant the idea in their minds.
No-suicide contract
Develop suicide prevention plans

EVALUATION
Despite superior nurse assessment and intervention, older adults still attempt suicide at alarming rates. When an older adult commits suicide, the
nurse may help the family and friends deal with the grief and pain. Uncovering the circumstances and behaviors surrounding the patient's suicide
may help both the medical team and the patient's family and friends. Support groups can also help family and friends.
PARKINSON DISEASE
Characterized by slowing in the initiation and execution of movement (bradykinesia), increased muscle tone
(rigidity), tremors at rest, and impaired postural reflexes The main area in the brain affected by PD is the basal
ganglia who is responsible for control both muscle tone and the process of voluntary movement.

CLINICAL MANIFESTATION
Fatigue and a slight resting tremor
Muscle rigidity, bradykinesia, and postural,abnormalities

PLANNING AND EXPECTED OUTCOME

Expected outcomes for a patient with PD include the following:
1. The patient will maintain an effective communication pattern.
2. The patient will maintain physical functioning and mobility and will not sustain injury.
3. The patient will maintain effective coping by demonstrating the use of coping strategies that enhance individual and family functioning.
4. The patient will maintain socialization by participating in activities.
5. The patient will verbalize satisfactory effects from medications and safely manage the medication schedule.

INTERVENTION
Teaching preventive measures for malnutrition, falls and other environmental hazards, constipation, skin breakdown from incontinence,
and joint contractures
Teaching gait training and exercises for improving ambulation, swallowing, speech, and self-care

EVALUATION
Evaluation is based on documentation of the achievement of expected outcomes, as evidenced by an older adult patient exhibiting intact
skin, appropriate body weight, effective communication, effective coping, and knowledge of appropriate self-care practices. Participation of
family members in continued care and rehabilitation is also noted. Specific problems are documented, as is any teaching.
CEREBROVASCULAR ACCIDENTS (BRAIN ATTACK)
A disruption in the normal blood supply to the brain tissue causes a CVA (stroke, or brain attack).

CLINICAL MANIFESTATIONS
Internal carotid: contralateral motor and sensory deficits of the arm, leg, and face.
Middle cerebral artery: drowsiness, stupor, coma, contralateral hemiplegia and sensory deficits of
arm and face, aphasia and homonymous hemianopia may be seen.
Anterior cerebral artery: contralateral weakness or paralysis and sensory loss of the foot and leg, loss of
ability in decision making and voluntary actions, and urinary incontinence
Vertebral artery: pain in the face, nose, or eye; numbness or weakness of the face on the ipsilateral side;
problems with gait; dysphagia; and dysarthria (difficulty speaking)

PLANNING AND EXPECTED OUTCOME

The patient will not die.
2. The patient will have minimum residual deficits and complications.
3. The patient’s increased ICP will be reduced.
4. The patient will not suffer evolution, extension, or completion of the stroke.

INTERVENTIONS
Encourage active range of motion on the unaffected side and passive range of motion on the affected side.
• Turn the patient every 2 hours.
• Monitor lower extremities for thrombophlebitis resulting from immobilization.
• Encourage the use of the unaffected arm for ADLs.
- CVA and CVA prevention
- Medications
ANXIETY
Anxiety is one of the most common symptoms seen in older adults; the most common anxiety disorder seen in
older persons is an obsessive-compulsive disorder. Anxiety disorders in older adults may develop as a result of
a specific event or a general pattern of change seen by patients as threatening.

PLANNING AND EXPECTED OUTCOME

1. The patient identifies his or her own anxiety and coping patterns.
2. The patient reports an increase in psychological and physiologic comfort.
3. The patient demonstrates effective coping skills, as evidenced by his or her ability to solve problems and
meet selfcare needs.
4. The patient demonstrates the use of appropriate relaxation techniques.

INTERVENTION
By creating coping skills for the worst case scenario, patients may feel more capable of coping with their current situation.
Teaching relaxation strategies

EVALUATION
Monitoring the progress toward achievement of the expected outcomes and documenting the results.
The effectiveness of any health teaching is evident in a patient’s ability to use relaxation techniques and constructive problem-solving.
SCHIZOPHRENIA
A thought disorder characterized by altered perceptions of reality, alterations in thought processes (both
form and content), and declines in patients’ ADLs and occupational and social functioning.

PLANNING AND EXPECTED OUTCOMES

1. The patient develops a trusting relationship, as evidenced by the presence of supportive significant others.
2. The patient maintains contact with mental health caregivers, as evidenced by weekly meetings with a
counselor.
3. The patient experiences a decrease in hallucinations and distress, as evidenced by verbalized reports of fewer
hallucinations and feelings of distress, as well as a demonstration of methods to handle hallucinations.
4. The patient gets adequate sleep, as evidenced by reports of sleeping through the night or verbalization of feeling rested
after a night’s sleep.

INTERVENTION
A comprehensive approach to the maintenance of ADLs, nutrition, hygiene, health promotion, and reality orientation.

EVALUATION
Evaluation is based on the achievement of the identified expected outcomes. It is often helpful to establish short-term goals for
patients with schizophrenia that are easily achievable and specific. The nurse is responsible for documenting progress toward
achievement of the objectives, as well as the level of safety achieved.
MENTAL RETARDATION
Below-average intellectual functioning

PLANNING AND EXPECTED OUTCOME

1. The patient demonstrates the ability to maintain personal safety, as evidenced by the ability to communicate
anger and frustration, appropriately use methods for coping with feelings, and exhibit appropriate self-control.
2. The patient demonstrates the ability to care for self independently within limitations, as evidenced by demonstration
of appropriate self-care activities on a regular, consistent basis with minimum supervision.

INTERVENTION
Customizing the care routines to their level of intellectual functioning

EVALUATION
In evaluating the care provided to older adult patients with mental retardation, the nurse should also be aware of the need for an
expanded nursing focus in this population.
Mental Health Care
Resources
HUMAN RESOURCES
Geropsychiatric nurses and geriatric mental health nurses are trained at the master’s level, usually in programs
that offer some combination of psychiatric or mental health nursing and gerontologic nursing coursework

PHYSICAL RESOURCES
Older patients with mental and emotional problems are increasingly being treated on an outpatient basis,
primarily because of available methods of payment. Some of these outpatient choices are as follows:
Community mental health centers (which may include emergency psychiatric services during the evening
or night)
The clinic or offices of a geriatric psychiatrist, geriatric mental health nurse, or advanced practice nurse
specializing in geriatric mental health
Senior partial-hospitalization programs where patients receive assessment, diagnosis, and treatment (including
various types of medications and other therapy) and return home in the late afternoon
In-home assessments, diagnosis, treatment, care, and followup in patients’ own residences

FINANCIAL RESOURCES
One of the greatest issues in the care of mental illnesses or disorders in older adults is the lack of adequate financial resources to provide for
needed care. For adults ages 65 or older, Medicare coverage is limited. An annual review of Medicare coverage for mental illness or disorders
is needed to keep current with governmental changes.
Medicare beneficiaries, who are required to pay a 20% co-payment for medical and surgical services but are held responsible for 50% of the
cost of mental health services. The General Accounting Office (GAO) reported that approximately 90% of all insurance plans impose some
restrictions on mental health benefits that are not placed on general medical care.
Trends and Needs
More people are treated in the home setting and in partial hospitalization and outpatient settings. Other
community organizations such as churches and congregations, senior citizens’ groups, and other social
organizations are developing programs to help older persons maintain their mental health by preventing
loneliness and depression.

Increased emphasis will be placed on improving the quality of care in long-term care facilities. The primary need is to focus more on
mental illnesses or disorders, psychosocial issues, and communication skills.

This goal may be accomplished through state legislation or the efforts of regulatory agencies. Emphasis will also be placed on
increasing gerontologic, geriatric, and geropsychiatric content in the curricula of medical, nursing, and social work educational
programs. Advocacy groups should work toward including more of such content in state licensing examinations.
 Topics:
Structural Age-Related Changes of Neurologic System
Micah Joyce
Maldo Assessment of Cognitive Function
Reporter
Cognitive Disorders Associated with Altered Thought Processes

Diagnostic Assessment of Altered Thought Processes

Donelyn Miole
Reporter
Treatment of Altered Thought Processes
Challenges In The Care Of Older Adults With Cognitive Disorders

Other Common Problems And Conditions

Hilarry Monte De
Ramos Mental Health Resources
Reporter Trends and needs
THE END!