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Dementia: A Neurocognitive Disorder Guideline at a Glance (Nursing Practice Guideline)

Dementia: A Neurocognitive Disorder Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 12/2017EArsenaultknudsen@uwhealth.org
1
Guideline Title: Dementia: A Neurocognitive Disorder
Effective Date: December, 2017
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
This content is extracted from the adopted source document: Fletcher, K. (2016). Dementia: A
neuro-cognitive disorder. In M. Boltz, E. Capezuti, T. Fulmer & D. Zwicker (Eds.), Evidence-based
geriatric nursing protocols for best practice 5th Edition (pp. 233-250). New York, NY: Springer
Publishing Company, LLC. Please refer to the source guideline for complete information.
Target Population
[Patients with dementia or at risk of developing dementia.]
Source did not explicitly identify target population.
Goals
A. Early recognition of dementing illness
B. Appropriate management strategies in care of individuals with dementia and their families
Clinical Questions Considered
Not provided by source document.
Definitions/Distinctions
1. Dementia (also referred to as a major neurocognitive disorder) is a clinical syndrome of
disruptions in cognition.
2. In addition to disruptions in cognition, dementias are commonly associated with changes
in function, mood, and behavior.
3. The most common forms of progressive dementia are AD [Alzheimer’s disease], VaD
[vascular dementia], DLB [dementia with Lewy bodies], and FTD [frontotemporal
dementia]; the pathophysiology for each is poorly understood.
4. Differential diagnosis of dementing conditions is complicated by the fact that concurrent
disease states (i.e., comorbidities) often coexist.
II. Practice Recommendations
These guideline recommendations are based on an expert’s systematic review of the evidence. The
synthesis of available literature is published within a textbook of evidence-based protocols that does
not include the strength of each individual recommendation. The sources of evidence are listed within
the full text reference list and a summary of the levels of evidence used is in section IV.
The rapid growth of the aging population is associated with an increase in the prevalence of
progressive dementias. It is imperative that a differential diagnosis be ascertained early in the
course of cognitive impairment and that the patient is closely monitored for coexisting
morbidities. Nurses have a central role in assessment and management of individuals with
progressive dementia.
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 12/2017EArsenaultknudsen@uwhealth.org
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Parameters of Assessment
No formal recommendations for cognitive screening are indicated in asymptomatic individuals.
Clinicians are advised to be alert for cognitive and functional decline in older adults to detect dementia
and dementia-like presentation in early stages. Assessment domains include cognitive, functional,
behavioral, physical, caregiver, and environment.
A. Cognitive Parameters
1. Orientation: person, place, time
2. Memory: ability to register, retain, recall information
3. Attention: ability to attend and concentrate on stimuli
4. Thinking: ability to organize and communicate ideas
5. Language: ability to receive and express a message
6. Praxis: ability to direct and coordinate movements
7. Executive function: ability to abstract, plan, sequence, and use feedback to guide
performance
B. Mental status screening tools
1. Folstein et al.’s [Mini-Mental State Exam] MMSE is the most commonly used test
to assess serial cognitive change. The MMSE is copyrighted and a comparable tool,
[St. Louis university mental Status exam] SLUMS, is in the public domain.
2. [Clock Draw test] CDT is a useful measure of cognitive function that correlates
with executive control functions.
3. Mini-Cog combines the CDT with the three-word recall.
When the diagnosis remains unclear the patient may be referred for more extensive screening and
neuropsychological testing, which might provide more direction and support for the patient and the
caregivers.
C. Functional assessment
1. Tests that assess functional limitations, such as the [Functional Activities
Questionnaire] FAQ and the [Functional Assessment Staging Test] FAST, can
detect dementia. They are also useful in monitoring the progression of functional
decline.
2. The severity of disease progression in dementia can be demonstrated by
performance decline in ADL and IADL tasks and is closely correlated with mental
status scores.
D. Behavioral assessment
1. Assess and monitor for behavioral changes, in particular the presence of agitation,
aggression, anxiety, disinhibitions, delusions, hallucinations.
2. Evaluate for depression because it commonly coexists in individuals with
dementia. The [Geriatric Depression Scale] GDS is a good screening tool.
E. Physical assessment
1. A comprehensive physical examination with a focus on the neurological and
cardiovascular system is indicated in individuals with dementia to identify the
potential cause and/or the existence of a reversible form of cognitive impairment.
2. A thorough evaluation of all prescribed, over-the-counter, homeopathic, herbal,
and nutritional products taken is done to determine the potential impact on
cognitive status.
3. Laboratory tests are valuable in differentiating irreversible from reversible forms of
dementia. Two laboratory tests specifically recommend in the initial evaluation are
thyroid function and B12. Structural neuroimaging with noncontrast CT or MRI
scans are appropriate in the routine initial evaluation of patients with dementia.
F. Caregiver/environment

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 12/2017EArsenaultknudsen@uwhealth.org
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The caregiver of the patient with dementia often has as many needs as the patient with
dementia so a detailed assessment of the caregiver and the caregiving environment is
essential.
1. Elicit the caregiver perspective of patient function and the level of support
provided.
2. Evaluate the impact that the patient’s cognitive impairment and problem behaviors
have on the caregiver (mastery, satisfaction, and burden). Two useful tools include
the [Zarit Burden Interview] ZBI and the [Caregiver Strain Index] CSI tools.
3. Evaluate the caregiver experience and patient/caregiver relationship.
Nursing Care Strategies
The [Progressively Lowered Stress Threshold] PLST provides a framework for the nursing care of
individuals with dementia.
1. Monitor the effectiveness and potential side effects of medications given to improve
cognitive function or delay cognitive decline.
2. Provide appropriate cognitive-enhancement techniques and social engagement.
3. Assure adequate rest, sleep, fluid, nutrition, elimination, pain control, and comfort
measures.
4. Avoid the use of physical and pharmacological restraints.
5. Maximize functional capacity: maintain mobility and encourage independence as long as
possible; provide graded assistance as needed with ADL and IADL, provide scheduled
toileting and prompted voiding to reduce urinary incontinence, encourage an exercise
routine that expends energy and promotes fatigue at bedtime, and establish bedtime
routine and rituals.
6. Address behavioral issues: Identify environmental triggers, medical conditions,
caregiver/patient conflict that may be causing the behavior; define the target symptom
(i.e., agitation, aggression, wandering) and pharmacological (psychotropics) and
nonpharmacological (manage affect, limit stimuli, respect space, distract, redirect)
approaches; provide reassurance; and refer to appropriate mental health care
professionals as indicated.
7. Ensure a therapeutic and safe environment: Provide an environment that is modestly
stimulating, avoiding overstimulation that can cause agitation and increase confusion and
understimulation that can cause sensory deprivation and withdrawal. Use patient
identifiers (name tags), medic alert systems and bracelets, locks, wander guard. Eliminate
any environmental hazards and modify the environment to enhance safety. Provide
environmental cues or sensory aids that facilitate cognition, and maintain consistency in
caregivers and approaches. Psychosocial interventions and cultural arts therapy in
dementia may prove beneficial.
8. Encourage and support advance care planning: Explain the trajectory of progressive
dementia, treatment options, and advance directives.
9. Provide appropriate EOL care in terminal phase: provide comfort measures, including
adequate pain management; weigh the benefits/risks of the use of aggressive treatment
(tube feeding, antibiotic therapy).
10. Provide caregiver education and support: Respect family systems/dynamics and avoid
making judgments; encourage open dialogue, emphasize the patient’s residual strengths;
provide access to experienced professionals; and teach caregivers the skills of caregiving.
11. Integrate community resources into the plan of care to meet the needs for patient and
caregiver information; identify and facilitate both formal (i.e., Alzheimer’s Association,
respite care, specialized long-term care) and informal (i.e., churches, neighbors, extended
family/friends) support systems.
Evaluation/Expected Outcomes

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A. Patient outcomes: The patient remains as independent and functional in the environment
of choice for as long as possible, the comorbid conditions the patient may experience are
well managed, and the distressing symptoms that may occur at EOL are minimized or
controlled adequately.
B. Caregiver outcomes (lay and professional): Caregivers demonstrate effective caregiving
skills; verbalize satisfaction with caregiving; report minimal caregiver burden; are familiar
with, have access to, and use available resources.
C. Institutional outcomes: The institution reflects a safe and enabling environment for
delivering care to individuals with progressive dementia; the quality improvement plan
addresses high-risk problem-prone areas for individuals with dementia such as falls and
the use of restraints.
Follow-up to Monitor Condition
A. Follow-up appointments are regularly scheduled; frequency depends on the patient’s
physical, mental, and emotional status and caregiver needs.
B. Determine the continued efficacy of pharmacological/nonpharmacological approaches to
the care plan and modify as appropriate.
C. Identify and treat any underlying or contributing conditions.
D. Community resources for education and support are accessed and used by the patient
and/or caregivers.
III. Pertinent Resources
A. UWHC Policy
ξ 13.12A, Basic Care Standards (Inpatient Adult)
B. Patient Education Resources
ξ Health Facts For You (HFFY) 5264, Daily Routines for a Person with Dementia
ξ HFFY 5265, Communicating with a Person with Dementia
ξ HFFY 5266, Caregiver Tips
ξ HFFY 5267, Emotional Changes and Dementia
ξ HFFY 6977, Memory Loss and Aging
ξ HFFY 7998 Dementia Facts
ξ HFFY 7999 When Your Loved One with Dementia is Hospitalized
C. Helpful Websites
ξ Alzheimer’s Association
http://www.alz.org
ξ Alzheimer’s Foundation of America: Excellence in Care
https://alzfdn.org/
ξ Alzheimer’s Disease Education and Referral Center
https://www.nia.nih.gov/alzheimers/about-adear-center
ξ American Association of Retired Persons (AARP)
http://www.aarp.org/caregiving
ξ ConsultGeriRN
htt ps: // co nsultgeri.o rg/
ξ ElderWeb
http://www.elderweb.com
ξ Hartford Institute for Geriatric Nursing
http://www.hartfordign.org/
ξ National Conference of Gerontological Nurse Practitioners: Mental Health Toolkit
https://www.gapna.org/resources/toolkits/toolkit-gerontology-resources-advanced-
practice-nurses
ξ The National Family Caregiver’s Association (NFCA)
http://www.nfcacares.org

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 12/2017EArsenaultknudsen@uwhealth.org
5
IV. References
See full guideline document for list of references.
V. Summary of Literature Used
Level of Evidence* Number of articles
I: Systematic Reviews 48
II: Single experimental study (RCTs) 5
III: Quasi-experimental studies 4
IV: Non-experimental studies 22
V: Case report/program evaluation/narrative literature reviews 25
VI: Opinions of respected authorities 6
* Level of evidence hierarchy extracted from source document: Levin, R.F. & Kaplan Jacobs, S. (2016). Developing
and evaluating clinical practice guidelines: A systematic approach. In M. Boltz, E. Capezuti, T. Fulmer & D. Zwicker
(Eds.), Evidence-based geriatric nursing protocols for best practice 5th Edition (pp. 3-11). New York, NY: Springer
Publishing Company, LLC.