Nursing Care of the

Older Adult in
Chronic Illness

Chronic Confusion
• Chronic Confusion is also referred as disorientation.

• An irreversible, long-standing, and/or progressive

deterioration of intellect and personality characterized
by :
- decreased ability to interpret environmental stimuli,
- decreased capacity for intellectual thought processes,
- disturbances of memory, orientation, and behavior.
• Confusion is a symptom that makes you feel as if you can’t think
clearly.

• Signs…
- Slurring words or having long pauses during speech
- Abnormal or incoherent speech
- Lacking awareness of location or time
- Forgetting what a task is while it’s being performed
- Sudden changes in emotion , such as sudden agitation
CAUSES:
- Age – (due to environment changes)
-injury ( concussion) head trauma, brain, spinal cord tumor
-Infection – CKD , CLD,
- Substance abuse medications(alcohol, drug intoxication)
- Dementia
TYPES:
1. Acute confusion - delirium
-has an abrupt onset, over hours or days and is
associated with an identifiable risk factor or cause.

• 2. Chronic confusion – dementia

-is a long-term, progressive, and possibly degenerative
process and occurs over months or years. Both
categories can befall in any age group, gender, or
clinical problem.
1. Delirium
is an acute transcient disturbance in consciousness that
is characterized by a change in cognition manifest primarily by
an impairment of attention

- inability to focus, sustain, or shift attention can result in

the impairment of other neurobehavioral tasks(e.g. memory)

-language and visual spatial skills also can be affected

• -changes in cognition seen in delirium are not explained by
an underlying dementia

• - these changes fluctuate considerably during a 24- hour

period and tend to be more pronounce at night
• Clinical Features & Findings:

Impairment of consciousness : clouding of consciousness ranging from

drowsiness to stupor and coma

Impairment of attention : difficulty in shifting, focusing and sustaining

attention

Perceptual disturbances : illusions and hallucinations, most often visual

- Disturbance of cognition :
impairment of abstract thinking and comprehension,
impairment of recent and immediate memory,
increased reaction time

- Psychomotor disturbances:
hypo or hyperactivity , aimless groping or picking at
the bed clothes( flocculation), enhanced startle
reaction
• Disturbance in sleep wake cycle:
insomnia or in severe cases total sleep loss, daytime
drowsiness, disturbing dreams or nightmares

• Emotional disturbances:
depression, anxiety , fear, irritability, euphoria, apathy
Management:
• Psychiatric management:
• -admit patient in psychiatric hospital
• Identify the course by taking psychiatric history, general
history and mental status examination
• Do the investigation
Nursing Management/ interventions
- Hospitalization
- admit the patient in psychiatric ward
- give comfortable bed to the patient
- if patient is agitated then use of physical restraint may
be necessary
- check the vital signs
Therapeutic Need
- Give the drugs prescribed by the psychiatrist regularly
- When giving oral medicine to the patient , see that whether
patient swallows the medicine or not
- Observe for any side effects
- Record the dose frequency in nurse record
Provide safe environment
- Restrict the environmental stimuli, keep unit calm and well
illuminated
- There should always be somebody at the patient’s bedside
reassuring and supporting
- As the patient is responding to a terrifying unrealistic world
of hallucinatory illusions and delusions, special
precautions are needed to protect him from himself and
to pretect others.
Alleviating patient’s fear and anxiety

• remove any object in the room that seems to be source of

misinterpreted perception
• As much as possible have the same person all the time by the
patients bedside.
• Keep the room well lighted specially at the nighttime
Meeting the physical patients need
• Appropriate care should be provided after physical
assessment
• Use of appropriate nursing measures to reduce high fever, if
present
• Maintain intake and output chart
• Mouth and skin care should be taken care of
• Monitor vital signs
• Observe patient for any extreme drowsiness and sleep as this
may be an indication that the patient is slipping into coma
Facilitate orientation
• Repeatedly explain to the patient where he is and what date ,
day and time it is
• Introduce people with name even if the patient misidentifies
the people
• Have a calendar in the room and tell him what day it is
• When the acute stage is over , take the patient out and
introduce him to others
2. CONFUSION / DEMENTIA
- is a change in mental status in which a person is not able
to think with his or her usual level of clarity.
- can leads to the loss of ability to recognize people and or
places, or tell time and date
- feelings of disorientation and decision-making ability is
impaired
- it may arise suddenly or develop gradually over time
- has multiple causes, including injuries, medical
conditions, medications, environmental factors and
substance abuse
Risk Factors for Dementia
- age
- family history
- genetic factors
- environmental factors
- history of head trauma
- vascular disease
Possible warning signs of dementia
- frequent forgetfulness, especially of recent events
- difficulty of common task
- forgetting common words
- becoming lost in familiar place/areas
- poor judgement, especially with finances
- misplacing objects in unusual places
- changes in mood , behavior or personality
- lack of interest/ involvement in life activities
ETIOLOGY
- Significant loss of neurons and volume in brain regions devoted to
memory and higher mental functioning

- Neurofibrillary angles( twisted nerve cells fibers that are the damaged
- remains of microtubules

- Environmental factors: infection , metal and toxins

- excessive amount of metal ions, such as zinc and copper , in the brain
Neurons of Alzheimer’s
• Deficiencies of vitamin B6, B12 and folate possible
risk factor due to increased levels of homocysteine
( amino acid that may interfere with nerve cell repair)

• Early depression: common genetic factors seen in those

with early depression and Alzheimer’s disease
Untreatable and irreversible cause of
dementia
• Degenerating disorders of CNS
• Alzheimer's disease ( the most common of all dementing
illnesses)

• Pick’s disease
• Huntington’s chorea
• Parkinson’s disease
Treatable and reversible causes
• Vascular – multi-infarct dementia
• Intracranial space occupying lesions
• Metabolic disorders
• Endocrine disorders
• Infections- AIDS, meningitis, encephalitis
• Intoxication- alcohol
• Anoxia –anemia, post –anesthesia , chronic respiratory failure
Types of
Dementia
DEMENTIA

- progressive, degenerative brain dysfunction including

deterioration in memory, concentration, language, skills
spatial skills and reasoning
- not considered as a normal part of aging
- most common type is ALZHEIMER’S disease
( Dr. Alois Alzheimer)
-
VASCULAR DEMENTIA
- the second most common type of dementia
- may occur after a cerebrovascular accident or stroke

MIXED DEMENTIA
- combination of Alzheimer and vascular dementia
- plaques and tangles are present along with blood vessel
changes associated with vascular dementia
Parkinson’s Disease
- chronic neurodegenerative disease characterized by motor
symptoms in the early stages, and cognitive and dementia
on later stage

Lewy body dementia

- variant of dementia with a specific pathological findings in
the brain ( abnormal deposit of a protein, alpha- synuclein)
Frontotemporal dementia( frontal lobe dementia)
- affects the frontal and temporal lobes of the brain and is
often characterized by early deficiencies in executive
functioning( planning and making decision)
- memory may remain intact
 ALZHEIMER’S Disease
Pathological of ALZHEIMER
- there numerous brain changes that contribute to the
symptoms
- hallmark of these changes are the beta- amyloid plaques and
neurofibrillary tangles
- the plaques are dense deposits around the neurons
- the tangles build up inside the nerve cells
- both plaques and tangles interfere with the normal nerve cell
function and this will lead to neuronal death
• Signs of Alzheimer’s disease
- Aphasia – loss of language ability, initially difficulty finding words,
eventually loss of all verbal ability

- Apraxia – loss of purposeful movement without loss of muscle

power or coordination

- Agnosia – loss of sensory ability to recognize objects

- Mnemonic disturbances – memory loss

STAGES OF ALZHEIMER’S

1. Early Stage - mild dementia (2-4 yrs)

-has difficulty remembering names and appointments
and may forget where things are placed.
-Have problems with spatial orientation, show affect
changes and seen emotionally unstable at times.
-Epileptiform seizure may occur along with
muscle twitching.
- Declining interest in environment
- Poor performance at work
2. Middle stage – moderate dementia
- presents with apparent cognitive deficits.
- May last from 2 – 12 years.
- Memory for past events mat still exist, but the person has
no recall of recent ones.
- Orientation and concentration are affected and has
increasing difficulty comprehending everyday events.
- there is restlessness at night and increased aphasia,
agnosia and apraxia
- former social habits are forgotten
- has hypertonia(increased tightness of muscle tone and
reduced capacity to stretch due to damage to motor nerve)
• Progressive memory loss
• Has difficulty in following simple instructions
• Irritable, anxious
• Wandering
• Neglects personal hygiene
• Social isolation
• Hesitations in response to questions
3. LATE STAGE DEMENTIA
- loss the ability to engage in the world
- communicating and expressing thoughts becomes difficult
- severe disorientation(does not recognize family )
- psychotic symptoms(delusion, disorientation, paranoid
ideation), severe agitation
- Kluver Bucy syndrome – hyperorality, hypersexuality,
bulimia, attempts to touch every object in
sight(hypermetamorphosis)
- bedridden, helpless
- death may results from pneumonia, malnutrition or
dehydration
• Incontinence of urine and feces
• Losses the ability to stand and walk
•Nursing Management
• Assessment data for the patient with dementia should include
a past health and medication history

• Data to be included:
-disorientation
-mood changes, fear
-suspiciousness
-self care deficit
- social behavior
-level of mobility, wandering behavior
- judgement ability
- sleep disturbances
- speech or language impairment
- hallucinations , illusions or delusions
- bowel , bladder incontinence
- apathy
- any decline in nutritional status
- recognition of family members
- identify family care giver, support system and the
knowledge base of the family members
 NURSING CARE
• A. PROMOTE
1. Normal Motor behavior
- living areas must be well lit and furniture must be left in same
place
- safety bars must be installed in toilets, showers and tubs
- teach safety use of walkers
- avoid crowds or large open spaces without boundaries
2. adequate sleep
3. optimal orientation
 4. optimal pattern of elimination
5. optimal nutritional status

B. MAINTAIN
1. self-care = allow patient to do mush as possible unassisted
2. optimal attention span
3. optimal perceptual functioning
C. SUPPORT
1. optimal memory function
2. optimal verbal expression
3. optimal role performance
• Conclusion:

• Dementia is a serious cognitive disorder and is a far

common in the geriatric population , but it may also
happen in any stage of childhood

- We nurses must be aware about the preventive measures

of dementia and educate the people about its signs and
symptoms together with the proper treatment.
 Differentiating delirium from dementia
Characteristics Delirium Dementia

onset acute Insidious

course fluctuating Gradual deterioration

awareness impaired Often clear until advanced stages

attention disturbed Often good until advance stages

memory Poor working and immediate recall Poor short- term memory

delusions Often short lived or changing More fixed

Sleep disturbances Fragmented sleep Sleep –wake reversal