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COGNITIVE AND MEMORI Submitted for the fullfillment of Perception, Sensory and Cognitive Instructore : Ns.

Elsa Naviati, S.Kep., M.Kep

By Selly Hning Pangastuti Ciptaningrum Marisa Prawarti Iwan Sulistio Wibowo Dennisa Rahayu Ningtyas Suwaryanti 22020110120007 22020110120011 22020110120050 22020110120074 22020110141012

SCHOOL OF NURSING FACULTY OF MEDICINE DIPONEGORO UNIVERSITY 2012

A. Cognitive development of the Elderly David Wechsler (1972) each person will experience intellectual decline, due to the aging process. John Horn (1980) argues that some abilities are declining, while other abilities are not. crystallized intelligence (crystallized intelligence = the set of information and verbal abilities of the individual) increases, with increasing age. While the intelligence that flows (fluid intelligence = the ability to think abstractly) definitely decreased since mid-adulthood. From various studies have been conducted found a few things: 1. Intellectual performance as measured by tests of verbal ability in the field vokabular (vocabulary), comprehension of information and peaked at ages 20-30 years and then persist throughout life, at least until the mid-80s age years, when no disease. 2. The ability to execute timed tasks, the associated time, which requires speed, eg speed of processing information, reaching a peak in about 20 years of age, then decreased gradually throughout life. 3. Although the pace of the decline is in part attributable to changes in the field of motor and perceptual abilities, obtained evidence that the speed of processing in the central nervous decreased with increasing age. This change was experienced by almost all people who reach the age of 70. However, deviations are also obtained, which some people do it the age of 70 years is better than 20-year-old. There is a decline in performance especially on tasks that require speed and also the tasks that require shortterm memory. Cognitive changes: 1. Setbacks are common in tasks that require speed and memory tasks that require short-term 2. Intellectual abilities do not decline. Intellectual disorder called progressive dementia that goes, come on slowly but progressively (usually monthly to yearly intervals). Dementia is a disorder of the most feared among the elderly, although these abnormalities are not visible existence. Old age

itself is not a direct cause of dementia, but dementia is a disorder caused by concomitant changes that take place in the central nervous system. Further depressive disorders are also a factor in intellectual decline is quite common, but often overlooked. Incidence of depression is found in 5-10% of the elderly in a community. The onset of depression caused by the presence of depressive mood is lasting at least two weeks with vegetative complaints (in the form of sleep disturbance, decreased interest, guilt, feeling powerful, lack of concentration loss of appetite, psychomotor symptoms, until the suicidal themselves). 3. Vocabular in verbal ability will persist in the absence of disease. 4. Changes in intellect, memory and other psychological variables has been widely studied in the elderly are "normal". B. Memory (remeber power, memory) Forgetfulness is a common complaint raised by the elderly. These complaints are usually taken for granted and the surrounding communities. This complaint is based on fact. Of research "cross-sectional" and found that most of the longitudinal-but not all, individuals experience impaired memory and learning to follow through age, especially after the age of 70. However, the decline rather than sub-systems that build memory and learning process, not a similar level of decline. Memory is a complicated process. Memory connects the past with the present. Many types of memory is known, for example, short-term memory and long-term, verbal and visuospatial memory; olfaktoar memory, auditoar, tactile and kinesthetic. 1. Memory processes The process of recording and retrieval of information that in mind can be simplified as follows: Input the information call (retrieval) a. Encoding Information can be stored in order for a note, on the register. This is the first level. This information is then transferred into memory, called registration output information encoding storage (storage)

encoding. Encoding conditions influence the degree of power or storage, for example: semantic encoding (storing according to the meaning, significance) normally provide a more powerful memory than phonological encoding (save by the sound). b. Storage (storage) "Storage" is the prosses by which information is maintained in memory. This is not a static information storage. This information network reorganized secar active. Stored information will be more powerful when used repeatedly, a process called konsodilasi. Storage of this information varies, for example, semantic memory, episodic memory, declarative memory, procedural memory. Example: Knowing what I eat breakfast time, it is episodic memory. Knowing the meaning of the word breakfast, the breakfast, is the ability semantic. Both types of memory can be also called declarative memory (memory of facts). Procedural memory is the memory of a skill and routine. For example, knowing how to drive a car merupaakan procedural memory. Knowing how car engines work is a declarative memory. c. Retrieval (calling back, recall) Retrieval is the process by which the information was recalled from memory. Memory can also be divided in terms of time, namely: immediate memory, short-term, new and long-term. In the immediate memory (immediate) subject to call back the stimulus given to him a few minutes earlier. This memory function is impaired in derilium. Short-term memory (short term) covers events over the last 30 minutes. This memory is impaired in amnesia syndrome. The new memory (recent) includes events between 30 minutes to a few weeks earlier. This memory can be impaired in various circumstances, such as delirium, amnesia and dementia syndromes. Long-term memory (remote) include those that are older than a few weeks ago.

C. Intellectual Capacity in Elderly The study found that the maximum attainable life of man is 116120 years old. Each of intellectual decline before age 50 is abnormal or pathological. By David Wechsler in Desmita (2008) deterioration of mental abilities is part of the aging process sacara common organisms, most of the studies show that after reaching a peak between the ages of 4555 years, most of the ability of a person is continuously decreasing, this is also true on an elderly person. The study found that brain function changes little or no change with age follow through, for example in the store (storage) of information. But the follow through age obtained a continuous decline than the speed of learning, speed of processing new information and react to the stimulus velocity is simple or complex. When the elderly showed a decline intelektualiatas began to decline, the decline is also likely to affect certain memory limitations. For example, someone who retire, who do not face the challenges of intellectual adjustment with respect to employment issues, and the possible use less memory or even less motivated to remember beberpa things, will clearly decline memory. Intellectual deterioration of the elderly in general is some thing that can not be avoided, due to various factors, such as illness, anxiety or depression. D. Factors Affecting Memory Memory is affected by numerous things including how alert you are when information is presented, how relevant or interesting the information is to you, whether the information is novel or is related to things you already know, how organized or detailed the information is, and the physical and mental context in which information is learned and later remembered. Memory and other mental abilities are also very sensitive to your physical state. For example, lack of sleep will undermine your memory, as will factors like fatigue, anxiety, and stress. Illness can also adversely

affect your memory and attention, from relatively minor illnesses such as colds, the flu, and infections, to more major illness such as diabetes, heart disease, obesity, liver arteriosclerosis. E. Factors Influencing Cognitive And Memory Function Cognitive function in people of all age is affected by multitude of internal and external factors. Nurses pay attention to identify the risk of influencing these factors toward elderly a. Personal and Social Influence Years of formal education is the factor most consistently associated with cognitive performance in adults and this association is independent of race and sex and cultural, geographic or other variables. Other personal characteristics that affect cognitive function include past and current socioeconomic status, the content of educational material, mental stimulation in the workplace, or a combination of these factors (Cagney & Lauderdale, 2002; Turrell et al., 2002) Ageism and diminished expectations of older adults in modern societies can negatively affect cognitive function. However, memory training can change false beliefs and improve performance (Hess, 2006) b. Sensory Function and Health Factors All cognitive processes are affected when hearing or vision impairments limit quality and quantity of information received from the environment. Many chronic condition and other aspects of physical health are correlated with cognitive abilities in older adults. The example of chronic conditions are : 1. Thyroid disorders Decreased production of virtually all hormones, parathyoid function and secretion is not changed, decreased basal metabolic consequences of thyroid activity to decline, decreasing production of aldosterone, decreased secreation of and kidney problems, hypertension, and

hormones gonads (progesterone, estrogen, and testosterone), lowering of the exchange of substances. 2. Diabetes and impaired glucose tolerance In aging process, the eldelry will easy to risk of diabetes mellitus. Generraly, diabetus mellitus in eldelry are

asymptomatic. If there are symptoms, often the symptoms are nottypical such as weakness, lethargy, behavioural changes, reduced cognitive status or functional ability (between another delirium, dementia, depression, agitation, it is easy to fall, adn urinary incontinence). This is what led to the diagnosis of diabetus mellitus in eldelry. 3. Dementia Dementia is the name for progressive loss of memory and other aspects of thinking that are severe enough to interfere with the ability to function in daily activities. Although there are many causes of dementia -- including blood vessel disease, drug or alcohol abuse , or other causes of damage to the brain -- the most common and familiar is Alzheimer's disease. Alzheimer's disease is characterized by a progressive loss of brain cells and other irregularities of the brain. 4. Cardiovascular disorders Heart valves thicknened and stiff, decreased ability to pump blood (decreased contraction and volume), decreased blood vessel elasticity, and increased peripheral vasculer resistance so that blood pressure increases. Anxiety is consistently identified as a condition that impairs cognitive abilities by causing excessive worry and self-doubts. Depression also contributes to negative self-expectation and interferes with attention and concentration, which are two cognitive skills that significantly affect memory. c. Nutrition and Chemical Factors

Nutritional status can affect cognitive function, particularly memory performance, regardless of a persons age. Good nutrition -including high-quality proteins and fats -- is important to proper brain function. Deficiencies in vitamin B1 and B12 specifically can affect memory. The brain needs fuel in particular from glucose. If someone is experiencing a fuel shortage or malnutrition, the brain power in the store will also be a short memory. Malnutrition can also cause severe retrograde and anterograde amnesia, including circuitry forget what you just said. Nutritional status can affect cognitive function, particularly memory performance, regardless of a persons age. Vitamin B12 protects neurons and is vital to healthy brain functioning. A lack of B12 can cause permanent damage to the brain. For example, low levels of beta-carotene, B vitamins, and vitamin C can negatively affect cognitive function. Studies have found that higher intake of vitamin E in food or supplements, is associated with improved cognitive function in older adults (Morris, 2002; Ortega, 2002).

d. Medication Effects Medication can interfere cognitive function in many ways, for example anticholinergic ingredients, contained in numerous

prescription and over-the-counter medications, significantly affect memory and other cognitive functions and are common cause of changes in mental status in older adults. A number of prescription and over-the-counter medications can interfere with or cause loss of memory. Possible culprits include: antidepressants , antihistamines, anti- anxiety medications , muscle relaxants, tranquilizers, sleeping pills, and pain medications given after surgery. Many drugs can cause cognitive problems and memory loss as a side effects, common in adults. Common drugs that affect memory and brain function include sleeping pills, antihistamines, blood pressure and arthritis medication, antidepressants, anti-anxiety medications, and painkillers. e. Alcohol, tobacco, or drug use

Excessive alcohol use has long been recognized as a cause of memory loss. Smoking harms memory by reducing the amount of oxygen that gets to the brain . Studies have shown that people who smoke find it more difficult to put faces with names than do nonsmokers. Illicit drugs can change chemicals in the brain that can make it hard to recall memories. If a person consumes alcohol in one night so he will experience an acute memory loss or dieknal with blocking. Binge drinking in young adults can be detrimental to the daily memory can even continue into adulthood. A study conducted on 400 men (40-80 years), shows that vascular risk factors, such as excessive alcohol consumption and high homocysteine levels, associated with a reduction in capacity and speed of information processing. f. Sleep deprivation Both quantity and quality of sleep are important to memory. Getting too little sleep or waking frequently in the night can lead to fatigue , which interferes with the ability to consolidate and retrieve information. It is when a person is sleeping, the brain functions by processing information from all what happened during the day, and form it into memories. When a person is sleep deprived or suffering from other sleep disorders, he or she will be at higher risks for developing several medical conditions, such as obesity, diabetes mellitus, hypertension, and heart problems, and it can have negative effects on a person's mental functions, specifically impaired retaining of new information and ability to learn new things. One good example of people who can attest the effects of sleep deprivation to their mental functioning are students who do all-nighters just to finish doing all school activities on time. g. Depression and stress. Being depressed can make it difficult to pay attention and focus, which can affect memory. Stress and anxiety can also get in the way of concentration. When you are tense and your mind is overstimulated or

distracted, your ability to remember can suffer. Stress caused by an emotional trauma can also lead to memory loss. Depression mimics the signs of memory loss. It is a common problem in older adults especially if one is less social and active than they used to be or if one has recently experienced a number of major life changes (retirement, a serious medical diagnosis, the loss of a loved one, moving away from home). Research has shown that men older with increased levels of epinephrine are more likely to suffer from mild cognitive impairment. h. Head injury A severe hit to the head -- from a fall or automobile accident, for example -- can injure the brain and cause both short- and long-term memory loss. Memory may gradually improve over time. Any brain function can be disrupted by brain trauma resulting in inattention, difficulty concentrating, excessive sleepiness, faulty judgment, depression, irritability, emotional outbursts, and slowed thinking. However, memory loss is one of the most common cognitive side effects of traumatic brain injury (TBI). Even in mild TBI, memory loss is still very common. The more severe the victim's memory loss after the TBI, the more significant the brain damage will most likely be. Some TBI-related amnesia such as patients unable to recall what happened just before, during and after the head injury is temporary. Temporary memory loss is often caused by swelling of the brain in response to the damage it sustained. But because the brain is pressed against the skull, even parts that were not injured are still not able to work. The patient's memory typically returns as the swelling goes down over a period of weeks or even months. Temporary memory loss may also be an emotional response to the stressful events surrounding a TBI. Damage to the nerves and axons (connection between nerves) of the brain may also result in memory loss. The brain cannot heal itself like an arm or a leg, so any function that is damaged during a TBI is

permanently impaired unless the brain learns how to perform that function differently. Fixed amnesia may include the loss of meanings of certain common, everyday objects or words, or a person may not remember skills he had before the TBI. A different kind of memory loss is called anteretrograde amnesia, which is an inability to form memories of events that happened after the injury. Doctors are not sure, exactly, why this happens, but some research has shown that it may have something to do with the fact that TBI's reduce the levels of a protein in the brain that helps the brain balance its activity. Without enough of that particular protein, the brain can easily overload and memory formation is affected. In general, symptoms of brain injury should lessen over time as the brain heals but sometimes the symptoms worsen because the patient's inability to adapt to the brain injury. It is not uncommon for psychological symptoms to arise and worsen after a brain injury. At the current time, there is no treatment for memory loss following TBI; if the memory does not come back on its own, it will be lost permanently. There is a great deal of research in the field of TBI and memory loss, but, sadly, there are no cures for TBI-related amnesia at this time. i. Stroke. A stroke occurs when the blood supply to the brain is stopped due to the blockage of a blood vessel to the brain or leakage of a vessel into the brain. Strokes often cause short-term memory loss. A person who has had a stroke may have vivid memories of childhood events but be unable to recall what he or she had for lunch. Stroke is a brain attack commonly caused either by a sudden loss of blood flow to the brain or by a bleeding inside the head. Eighty percent of all strokes are called ischemic due to loss of blood flow. About 20% of strokes are called hemorrhagic due to bleeding. Large ischemic strokes are usually caused by narrowing of the large arteries in the neck and brain due to atherosclerosis. If the clot

forms in the neck vessels, pieces can break off and block the brain vessels. Clots may also arise from the heart and travel to the brain vessels where they become lodged. Large ischemic strokes usually give symptoms such as muscle weakness, loss of feeling, speech and vision problems, double vision, headache, unsteadiness, sleepiness, and sometimes death. People with uncontrolled high blood pressure and diabetes often have small ischemic strokes that involve very small arteries in the brain. Small ischemic strokes may not cause any symptoms. It is not unusual to find these asymptomatic, or silent strokes on brain scans that are done for other reasons. It is estimated that approximately one third of stroke victims will develop memory problems and serious difficulties in other aspects of performing daily activities. The memory problems can be so severe that they interfere with normal functioning and are then called dementia. This is more common as people get older. When dementia occurs after a stroke and no other cause can be found it is called vascular dementia. Both large strokes strategically located in certain areas of the brain or multiple small strokes can result in vascular dementia. Certain features like old age, prior memory problems, a history of several strokes, or a stroke located in the left side of the brain all seem to increase the likelihood of dementia in the first year after stroke. J. j. Hypnotic. During this hypnotic known to express one's memory of repressed or forgotten, but sometimes the process is followed with some memory loss known as amnesia pascahipnotis. k. Other causes. Other possible causes of memory loss include an underactive or overactive thyroid gland and infections such as HIV , tuberculosis , and syphilis that affect the brain. HIV-associated dementia (HAD) results from infection with human immunodeficiency virus (HIV) that causes AIDS. HIV-associated dementia may lead extensive damage to

the white part of the brain. This leads to type of dementia that generally includes disruption memory, apathy, social withdrawal, and difficulty concentrate. People with HIV-associated dementia is often motion problems as well. There is no treatment specific for HIVassociated dementia, but AIDS drugs can be delay the disease and may help reduce symptoms. F. Cognitive Development The considerable research on cognitive abilities and aging is currently being conducted. Intellectual capacity includes perception, cognitive, agility, memory, and learning. Perception, or ability to interpret the environment, depends on the acuteness of the senses. If the aging persons sense are impaired, the ability to perceive the environment and react appropriately is diminished. Perceptual capacity may be affected by changes in the nervous system as well. Cognitive ability, or the ability to know, is related to perceptual ability. An older man, for example, may know that he will be retiring next year but be unable to plan for retirement. He cannot accept the knowledge pscychologically because his work provides his sense of worth, self esteem, and identity. Changes in cognitive structures occur as a person ages. It is believed that there is progressive loss of neurons. In addition, blood flow to the brain decreases, the meninges appear to thicken, and brain metabolism slows. As yet, little is known about the effect of these physical changes on the cognitive functioning of the older adult. Neurofibrillary tangles have also been found in the hippocampal cortex, the area of the brain concerned with memory. A neurofibrillary tangle is an abnormal mass of fibrillar material found in the cytoplasm. Neuritic plaques are also found in the aging brain. A neuritic plaque is a structure composed of amyloid material surrounded by abnormal neural structures.

Neurofibrillary tangles and neuritic plaques could account for some of the functional changes found in normal aging people. Another change noted in the brain of the elderly is the deposition of lipofuscin. Lipofuscin is a brown colored waste material having a lipid base that accumulates within

the nerves as well as cardiac and skeletal muscle tissues. The effect of lipofuscin is unknown but is postulated to affect neuronal functioning. Memory, or the ability to retain information, is also a component of intellectual capacity and is closely related to learning. Thomas (1992) describes four stages of memory in the information processing model; sensory memory, primary memory or working memory, secondary memory and tertiary memory. Sensory memory, the first stage, is the momentary perception of stimuli by the senses. New information from the visual and auditory senses is temporarily stored in sensory memory during this stage (e.g., visual information is stored in visual, or iconic, memory; auditory information is stored in auditory,or echoic, memory). Primary memory also called shortterm memoy, is what one has in mind at a given moment. An example of primary memory is when you call information for a telephone number and remember the number only for the brief time needed to dial the number. There is limitted storage capacity and duration in primary memory. Working memory is the term applied to the processes of manipulating or reorganizing information in primary memory. There is generally little age difference in primary memory; however, there do appear to be age related differnces in working memory. For information to be retained, it must enter secondary memory. Secondary memory, also referred to as recent memory, includes the memory capacities that one uses on a daily basis. This includes memory about current evets, a book recently read, or a movie recently viewed. Most age related differences occur in secondary memory. The final stage of memory is tertiary memory. Other terms for tertiary memory are long term memory and remote memory. Tertiary memory is the repository for information stored for very long periods. (Thomas 1992, p. 168). Memories of childhood friends, teachers, and events care stored in tertiary memory. Elderly clients who remember the flowers in their wedding bouquet or the names of the boys on their dance card are drawing from tertiary memory.

Older people need addtional time for learning, largely because of the problem of retrieving information. Motivation is also important. Older adults have more diffulty than younger ones in learning information they do not consider meaningful. It is suggested that the older person remain mentally active to maintain cognitive ability at the highest possible level. Lifelong mental activity, particularly verbal activity, helps the older person retain a high level of cognitive function and may help maintain longterm memory. Cognitive impairment that interferes with normal life is not considered part of normal aging. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal. Family members should be advised to seek prompt medical evaluation. G. Some Aspects of Cognitive Development Cognitive decline of aging on the mark - the cognitive decline include: forgetfulness, memory is not functioning properly, the general orientation and perception of time and space, despite having much experience in the achieved scores in intelligence tests is lower and does not easily accept the idea- new ideas. 1. Intelligence and Ability to Process John Horn (1980) argues that some abilities are declining, while the other capabilities that tidak.Horn crystallized intelligence (crystallized intelligence = the set of information and verbal abilities of the individual) increases, with increasing age. While the intelligence that flows (fluid intelligence = the ability to think abstractly) definitely decreased since mid-adulthood. Of many studies (Baltes, Smith & Staudinger, in press;; Dobson, et al, 1993; Salthouse, 1992, 1993, in press; Salthouse & Coon, 1993; Sternbern & McGrane, 1993), is widely accepted that the speed of information processing have decline in late adulthood. Other studies have shown that adults are less able to issue a back-up information already stored in memory.

Information processing speed slowly indeed to decline in late adulthood, but individual differences also play a factor in this case. Nancy Denney (1986) stated that most of the tests ability to remember and solve the problem of measuring how grown-up people doing activities that are abstract or simple. Denney found that the ability to solve practical problems, in fact it increased at the age of 40's and 50's. In another study Denney also found that individuals in the age of 70 is no worse in pemecehan practical problems when compared to those in their 20s. General decline in the function of the nervous system can affect the processing speed informasi.walaupun Thus, the decline could restrict certain processing tasks, and can vary per individual. Steatle longitudinal study found that cognitive function in elderly people varies slightly decreased in all or most of a particular field. Cognitive decline is often caused by lack of use of cognitive abilities in the past. Many older athletes can regain his physical strength, and the elderly who receive training, practice and social support seems to utilize his mental reserves. Adults can maintain or expand these reserves and avoid cognitive decline by engaging in long-term mental training program

2. Memory a. Short-Term Memory Researchers assessed the short-term memory by asking someone to repeat a series of numbers, both in sequential order to the front and reverse (backward digit span). The ability to sort the numbers in the future will continue to persist with increasing age. However, not so with the performance of the series upside down, for the next repetition of the series requires only a sensory memory, the efficiency continues to persist throughout life while the inverted repeat sequence claimant information processing in working memory (working memory), the ability to decline gradually from about age 45 year.

The main factor is the complexity of the task. Tasks that only require the loop will show no significant decrease while the demanding task of reorganization or elaboration would show a bigger drop. b. Long-Term Memory Long-term memory component of the most decline with age. The ability to remember, especially the new information in the can appears to be declining. The researchers divided the information processing longterm memory into three main components, namely: a) Episodic Memory Long-term memory or experience certain events connected to the time and place. Elderly have many similar experiences that tend to run concurrently. When the elderly viewed the event as something different, they may remember as the young. b) Memory Semantics Long-term memory is factual knowledge of the general customs and language. The memory stores factual knowledge of history, geographic location, customs, and something that never happened. This memory decline with age. c). Procedural Memory Long-term memory motor skills, habits, and ways of doing things that often can be called back without any deliberate effort on the tang. Early decrease in prefrontal cortex could be a common cause memory problems such as the elderly, and supposed to forget the promise that in the imagined events as true - really happened. The possibility that the deterioration of neurological impairment caused some specific capabilities does not mean that nothing can be done to overcome them. Elderly can increase the assessment by taking into account aspects of the factual, not emotional of a situation and be more careful - careful and critical in the evaluation of where the "memory" is derived. To help improve memory in older adults. Several researchers have offered a training program that mnemonics techniques designed to help

people remember, such as visualizing a list of items, make associations between faces and names, or transform the various elements of the story into a mental image. The elderly will learn best if the dam material change in the method used to consider the psychological, physiological and cognitive impairment they may experience 3. Wisdom Ericson view policy as an aspect of personality perkenbangan the twilight. Other investigators define wisdom as an extension of formal post thoughts, the synthesis of reason and emotion. Robert Sternberg classifies wisdom as cognitive abilities can be learned and tested. Wisdom is a special form of practical intelligence that has a moral aspect. The use of latent wisdom and knowledge aimed at achieving the common good by balancing the various interests, often conflicting Referring Baltes study, no age-related policies, but all the people at all age levels respond more wisely on issues that affect their own age group. Wisdom has an interactive aspect. In one experiment both young and old gave a wise answer. When given extra time to think about the issue after discussing it with your spouse, relative, or friend of the older participants gave an answer that is more wise in comparison to younger ones. H. Post-Stroke Dementia 1.1 Definiton Dimentia Definition of dementia based on International Classification of Disease, 10th revition (ICD 10) is a condition of deterioration of intellectual functions including memory and thought processes, thereby disrupting the activities of daily living. Typical of memory disorders affecting the registration, storage and retrieval of information. In this case there must be a disorder of thinking and reasoning processes in addition to memory.

Dimentia is a general term for a permanent or progressive organic mental disorder that is characterized by personality changes, confusion, disorientation, deterioration of intellectuall functioning, and impaired control of memory, judgment, and impulses (Wold 1993, p. 75) Vascular dementia is a syndrome of progressive decline in intellectual ability that causescognitive and functional decline,causedby cerebrovascular disorders. Dementia afterstroke is part of vascular dementia, the dementia that arises as a direct result of a stroke, either ischemic or haemorrhagic stroke. Classification of vascular dementia is clinically according to Noble PERDOSSI FunctionStudy Group are: 1. Dementia after stroke a) Cerebral infarction dementia b) Dementia intracerebral hemorrhage 2. Subcortical vascular dementia a) Ischemic white matter lesions b) Subcortical infarcts lakuner c) Non lakuner subcortical infarcts d) Mixed-type vascular dementia (Alzheimer dementia and vascular dementia). 1.2 Etiology Dimentia In general, the etiology of dementia are: 1. Degenerative: for example in Alzheimer's dementia 2. Non-degenerative diseases: genetic, vascular disorders 3. Mixture The causes of vascular dementia, in this post-stroke dementia, is a disturbance incerebral blood vessels. Disorders that cause dementia, especially in post-stroke isatherosclerosis. atherosclerosis in blood vessels of the brain associated with variousrisk factors for stroke. Various risk factors are divided into irreversible and can be changed. Which can not be changed include age, gender, and genetic factors. Whichcan be changed including levels of fat or cholesterol in the blood,

high blood pressure,smoking, diabetes, heart disease, obesity, physical activity and stress less. 1.3 Manifestations of cognitive impairment and memory Disorders of cognition: a function is most commonly impaired in dementia patients,especially the disruption of abstraction. He always thought concrete, so it's hard to give meaning to proverbs. Also the equation (similarities) has decreased. Memory impairment: Given disorder is often the first to arise in early dementia. In the early stages of the newmemory is impaired, which quickly forgot what he had just done. But gradually the old memory can also be disrupted. In clinical neurology of memory functions are divided intothree levels depending the length of time between stimulus and recall are: 1. Immediate memory, span of time between stimulus and recall just a few seconds. Here only the concentrationneeded to remember. 2. Recent memory, longer time span is a few minutes, hours, months and even years. 3. Remote memory, time span of many years even a lifetime 1.4 Impaired Cognitive Function After Stroke Recovery of cognitive function after stroke varies. Research shows 83% of patients with verbal memory deficits, 78% of patients with disorders visuospasial construction and visual memory deficits improved within 6 months, while other cognitive domains showed less improvement. Another cohort study showed attentional problems was obtained in 54% of patients after 1 year, while the deficit in executive function, language, and long-term memory is much less frequent. Stroke patients may experience progressive cognitive decline postacute period, although there are no clinical features of recurrent stroke. In general, there is comorbidity in patients with stroke such as hypertension, diabetes mellitus, dislipidemi, which is also a risk factor for cognitive impairment. The first stroke also increases the risk of

subsequent stroke, whether or not lead to clinical manifestations (silent brain infarction). Patients with multiple infarcts in the brain had significantly memory performance, processing speed and poorer executive function. Impaired cognitive function after stroke may be a continuation of impaired cognitive function as an acute stroke, or due to uncontrolled stroke risk factors that cause abnormal blood vessels (alterosklerosis, arterial stiffness, endothelial dysfunction), and comorbidities that also affect cognitive functions, such as eg systemic diseases, disorders of the organs (heart, lungs, kidneys), Alzheimer disease, Parkinson's, depression. Types of cognitive impairment may be a disorder that occurs in a single cognitive domain (attention, language, memory, visuospasial, or executive function), or a combination of them. Malfunctioning konginif on a single domain are rare, more often in the form of the spectrum belonging to the "vascular cognitive impairment" (vascular cognitive impairement = VCI). Yet there is a clear division of VCI, VCI, but is generally classified into 3 subtypes: 1. Vascular dementia Dementia is a syndrome of cognitive impairment may manifest memory impairment, accompanied by two or more impairment of other cognitive modalities (orientation, attention, language function, visuospasial function, executive function, motor control, praxis) severe enough to cause interference with daily activities as evidenced with clinical examination and

neuropsychological testing. 2. VCI that does not meet the criteria of dementia (vascular cognitive impairement, no dementia = VCIND) 3. Alzheimer's disease with vascular components

The process of aging in the central nervous system characterized by the degeneration of neurons accompanied by gliosis. Reduction is not the same neurons in parts of the brain, the frontal and temporal

lobes have a greater reduction than other parts of the brain. The collapse followed by the collapse of neuron dendrites. There were also neuritic plaque formation and neurofibril tangles. 1.5 Hypertension Research shows that hypertension is a risk factor for impaired cognitive function indepneden, both with and without a history of previous stroke. High blood pressure in middle age (40-64 years) is a risk factor for cognitive decline in old age. High systolic blood pressure (> 180 mmHg) in the elderly is a risk factor for dementia. Hypertension is also associated with lesions larger sunstansia alba, a smaller brain volume, cortical or subcortical infarcts or hidden in strategic places, and the loss of brain volume in the thalamus or temporal lobe that are important in cognitive processes. I. Nursing Process Case: Mr. disorder signs. D, aged 65 years and lived with ank-law and two grandchildren. Son of Mr. D was upset because the last three months of Mr. D often forget their way home when going to the mosque. Whereas in the past six months, Mr. D is easy to forget the incident that just happened. Mr. D had stroke three years ago and hypertension since the age of 50 years. A. Data Collecting 1. Recently Medical history a. The main complaint: the client is often forgotten the way home b. Precipitating factors: aging c. Initial attack: 6 months ago d. Clients often forget the way to go finish of worship in the mosque about 3 months.

2.

Past Medical history Clients ranging from age 50 years had hypertension, 3 years ago a client suffers a stroke, 6 months ago, clients often forget the incident that just happened.

3.

Family health history No family members who suffer from the disease declined.

4.

Activity and exercise a. rest activity breaks clients usually water the plants in the morning, sit down chat with neighbors, nap, prayer to the mosque. b. Nutrition clients to eat three meals a day, the client drink 2-3 glasses of water and tea c. elimination Defecate once a day, no pain during defecation Urinate 4-5 times a day, no pain when urinating d. Personal hygiene Clients bath 2 times a day, brush your teeth 2 times a day, wash 3 times a weekAspek

Assessment A. Phsycal assessment a. Generally condition Awareness Breathing : komposmentis : 21 x/menit TD : 170/80 mmHg

Pulse : 76 x/menit

b. Head Head lesions Hair Eye masses. Ear Nose : symmetric, hearing is less, : no secret, no lesions : gray color, no masses, skin hair clean : conjunctiva clear, sclera white, no lesions, no : symmetric, face no weakness, normocephalic, no

Mouth

: mucosa pink, no masses, no lesions, tongue

protrudes in midline. c. Thorax Inspection Palpation Percussion : chest expansion symmetrical, no cough : no pain : resonant

d. Back Kifosis e. Abdomen Inspection Percussion Palpation Auscultation : symmetric with no apparent masses, no lesions : tympany : no pain, no lesions : peristaltik, normoactive.

f. Ekstremitas upper : no lesions, tremor, changes in pigmentation,

reduced muscle strength, no edema, no muscles pain, weakness. , warm to touch, dry smooth, no masses lower : no lesions, no muscles pain, weakness, warm to

touch, dry smooth, no edema, no masses, reduced muscle strength, no pain, tremor. B. Psychology a. mental aspects Clients receive state of her that was old. b. aspects of intellectual Client is easy to forget the places and events that just happened. Clients easily offended if reminded. c. Social aspects of economic The client is a retired teacher, client relationships with family and good neighbors. Around the house the client, the client in tetuakan. Adequate retirement income from daily life, but it also lives with her clients. d. Spiritual aspects client pray regularly

e. Environmental Aspects clients environmental is clean, there is health service. How to do Assessment ? A. Trusting relationships with elderly clients. 1. To conduct the assessment in the elderly with dementia, first you must build a trusting relationship with elderly patients. 2. To be able to build trusting relationships, things can be done as follows: a. Always say hello to the patient such as: good morning / afternoon / evening / night or in accordance with the religious context of the patient. b. Introduce your name (nickname) brothers, including the pass that the brother is a nurse who will care for patients. c. Ask also the name of the patient and his favorite nickname. d. Explain the purpose of caring for patients and relatives the activities to be performed. e. Explain when the activity will be implemented and how long the activity. B. Be empathetic manner: 1. 2. 3. 4. 5. Sitting with a client, make eye contact, give a touch and show concern To talk slow, simple, and give clients time to think and respond Nurses have the expectation that clients will be better Be warm, be simple to express the hope on the client. Use short sentences, clear, simple and easily understood (avoid using jargon words or phrases) 6. Speak slowly, say the word or phrase that is clear and if the response of patients waiting To question 7. Asked one question each time and re-ask the question with the same words. 8. Volume increased if there is hearing loss, if the volume is increased, the tone should be lowered. 9. The attitude of non-verbal communication along with good verbal

10. Attitude should communicate face to face, maintain eye contact, relaxed and open 11. Create a therapeutic environment when communicating with clients: a. No noise or fuss

b. Comfortable rooms, adequate light and ventilation c. Distance adjusted, minimize disorders. 12. Assessing elderly patients with dementia as well as behavior observe patients for signs as follows: a. lack of concentration b. Less personal hygiene

c. Prone to accidents: falls d. Not knowing the time, place and person e. Tremor f. Lack of coordination of movement g. limited activity h. Often repeat the words.

A. Nursing Diagnosis Based on the signs and symptoms found at the time of assessment, then the set of nursing diagnoses: a. Thought process disorder b. Risk of injury: falls

B. Intervention Diagnosis I "Elderly depression with impaired thought processes; dementia / forgetfulness." Action for the patient Objectives allow the patient to: a. Know / oriented towards the people and time b. Do activity daily optimally

Intervention 1. Give a chance for patients to recognize his personal belongings such as beds, cupboards, clothes etc. 2. Give the opportunity for patients to know when to use a large clock, a calendar that has a large sheet of paper per day with. 3. Give the patient a chance to say his name and family members 4. Give the opportunity for clients to know where he is. 5. Give praise when the patient when the patient can answer correctly. 6. Observation of the patient's ability to perform daily activities 7. Give the patient the opportunity to choose activities that can be done. 8. Help the patient to engage in activities that have been chosen 9. Give praise if the patient can perform activities. 10. Ask if the patient feel able to do activities. 11. With patients to schedule their daily activities.

Action for the familly The goal of keeping families a. Families are able to orient the patient to time, people and places b. Provide advice needed to conduct patient-oriented reality c. Assist patients in performing daily aktiftas. Intervention 1. Discuss with family-oriented ways of time, person and place in a patient 2. Encourage families to provide a large clock, a calendar with large text 3. Discuss with your family has ever had the ability of patients 4. Bantu families who do choose the ability of patients at this time. 5. Encourage the family to give praise to the ability to kemampauan which is still owned by the patient 6. Encourage families to the elderly carried out in accordance memantu capabilities 7. Encourage the family to monitor the daily activities of patients according to the schedule have been made.

8. Encourage the family to give praise to the ability of the patient's possession 9. Encourage families to help patients perform activities according to the capabilities 10. Encourage the family to give a compliment if the patient carried out in accordance with the schedule of activities that have been made.

Diagnosis II "Elderly dementia with a risk of injury" Action in patients. The goal of keeping the patient: a. Patients are spared from injury b. Patients are able to control activities that can prevent injury.

Intervention 1. Describe the risk factors that cause injury Dapa in simple language 2. Teach ways to prevent injuries: if the fall do not panic but cry out for help 3. Give praise to the ability of patients to mention the ways to prevent injuries.

Action for the family Purpose: Families are able to: 1. Identifying factors that could cause injury to the patient 2. Families are able to provide a safe environment to prevent injury

Intervention 1. Discuss with family factors that may cause injury to the patient 2. Encourage families to create a safe environment such as: floors are not slippery, keep sharp objects out of reach of patients, provide adequate lighting, the lights on during the day, let the tool handle and watch if the patient smokes, cap plugs and other electrical equipment with plaster, avoid power tools other than the range of clients, provide a low bed

3. Encourage families to always accompany the patient at home and monitor the daily activities undertaken

C. Evaluation To measure the success of nursing care that you do, it can be done by assessing the ability of clients and families: 1. Disorders thought process: confused Ability of the patient: a. Unable to name the day, date and year are now correctly b. Being able to name the person who is known c. Unable to name the place where the patient is currently d. Able to perform daily activities according to schedule e. Being able to express his feelings after making activities

Ability of family a. Able to help patients recognize the time and people temapt b. Provides a calendar that has a large sheet of paper and a day with a big clock c. Help patients perform daily activities according to the schedule have been made d. Giving praise whenever patients were able to carry out daily activities

2. Risk of injury Ability of the patient: a. Mention the simple language of the factors that cause injury b. Using the proper way to prevent injury c. Control activities according to ability

Ability of family a. Families can reveal the factors that could cause injury to the patient b. Provide safety in the home c. Distancing power tools out of reach of patients

d. Always accompany the patient at home e. Monitor the patient's daily activities are performed

A. COGNITIVE TRAINING STRATEGY a. Lowering anxiety b. Relaxation techniques c. Biofeedback, using a tool to reduce anxiety and modify the behavioral responses. d. Systematic desenzatization. Designed to reduce behaviors associated with specific stimulus such as altitude or travel by airplane. These techniques include muscle relaxation by imagining situations that cause anxiety. e. Flooding. Clients immediately exposed to the stimuli that trigger the anxiety (not done gradually - gradually) by using the shadow / imagination f. Client response prevention. Clients are supported to deal with the situation without making a response that is usually done.

B. COGNITIVE THERAPY a. Practice social skills include: asking questions, giving greetings, spoke clearly, avoiding kiritik self or others b. Aversion therapy: This therapy helps reduce unwanted behavior but continue to be made. This therapy provides stimulation to make anxious or rejection at the time of booking clients maladaptive behavior. c. Contingency therapy: Includes formal contract between client and therapist about what the definition of behavior to be changed or the consequences of that behavior when it is done. Include positive consequences for desired behavior and negative consequences for undesirable behavior.

REFERENCES 1. 2. Miller, Carol A. Nursing for Wellness in Older Adults. Lippincott Kozier et all. 1995. Fundamental Of Nursing concepts, Process, and practice. California:Wesley 3. pro-health. 2009. Dimensia pada Lansia.

http://stikeskabmalang.wordpress.com/2009/10/03/demensia-padalansia-3/ diakses pada 13 mei 2012. 4. Anonim. 2003. Askep keperawatan.

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http://weenbee.wordpress.com/2011/09/28/latihan-kognitif-padalansia/ diakses pada 13 mei 2012. 6. http://www.webmd.com/brain/memory-loss diakses pada 13 mei 2012 jam 23.40 7. http://en.wikipedia.org/wiki/Memory_loss diakses pada 13 mei 2012 jam 23.46 8. http://www.mindsrefined.com/aging.shtml diakses pada 14 Mei 2012 9. Anonim. http://www.esc-creation.org/showthread.php?tid=6531. Accessed on May 12nd, 2012 10. Afirmanto. 2010. Perkembangan Psikologi dan kognisi pada masa dewasa akhir.

http://afirmanto.blogspot.com/2010/04/perkembangan-psikologidan-kognisi-pada.html diakses pada 13 Mei 2012 11. pro-health. 2009. Dimensia pada Lansia.

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