Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Nursing Practice Guidelines,Related

Dementia Full Guideline

Dementia Full Guideline - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related

Dementia is most commonly de�ned as a clinical syn-
drome of cognitive decline. �e term dementia was elimi-
nated and replaced with “major or minor neurocognitive
disorder” in the latest Diagnostic and Statistical Manual
on Mental Health Disorders (5th ed.; DSM-5; Ameri-
can Psychiatric Association, 2013). It was felt that the
term dementia was stigmatizing and the focus should
be on decline rather than de�cit. Because these changes
are confusing to many health care professionals and the
term dementia remains established in the literature, the
terms dementia and neurocognitive disorder are used inter-
changeably in this chapter. In addition to disruptions in
cognition, dementia is associated with a gradual decline in
function and changes in mood and behavior.
�ere are many causes of dementia and dementia-like
presentations. Di�erentiating these changes early in the
course of illness is important because condition-speci�c
assessment, monitoring, and management strategies can
be employed. Di�erential diagnoses among conditions
that cause cognitive impairment are confounded by the
fact that these conditions may coexist and disparate neu-
rocognitive disorders may be similarly clinically expressed.
Major goals in the clinical approach to a person pre-
senting with cognitive impairments are identi�cation and
resolution of potentially reversible conditions (e.g., delir-
ium, depression), recognition, and control of comorbid
conditions, early diagnosis and management of a neuro-
cognitive disorder, and the provision of caregiver support.
�e focus of this chapter is on assessment and manage-
ment of the major neurocognitive disorders.
Global estimates re�ect that 44.4 million people have demen-
tia today, which will increase to 75.6 million by 2030 and
135.5 million by 2050 (Alzheimer’s Disease International,
2013). �e rapid growth of the older adult population in the
United States is associated with a signi�cant increase in the
prevalence of dementia. Dementia a�ects about 11% of indi-
viduals 65 years and older (Alzheimer’s Association, 2015).
�e prevalence increases exponentially with age, rising to
Dementia: A Neurocognitive Disorder
Kathleen Fletcher
On completion of this chapter, the reader should be able to:
1. Describe the spectrum of dementia syndromes
2. Recognize the clinical features of dementia
3. Discuss pharmacological and nonpharmacological approaches in the management of dementia
4. Develop a nursing plan of care for an older adult with dementia
For a description of evidence levels cited in this chapter, see Chapter 1, “Developing and Evaluating Clinical Practice Guidelines:
A Systematic Approach.”
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234  III: Clinical Interventions
nearly 32% in individuals 85 years and older (Hebert, Weuve,
Scherr, & Evans, 2013). More than 4.7 million individuals in
the United States have the most common form of demen-
tia, Alzheimer’s disease (AD), a number that is projected to
increase to 13.8 million by 2050 (Hebert et al., 2013).
�is chapter discusses the most common forms of
progressive dementia, AD, vascular dementia (VaD),
dementia with Lewy bodies (DLB), and frontotemporal
dementia (FTD). Less common, though not less signi�-
cant, is progressive dementia associated with Parkinson’s
disease (PDD), dementias associated with HIV, and
Creutzfeldt–Jacob disease.
AD, the most common form of dementia, accounts
for more than 80% of all cases. A chronic neurodegenera-
tive disease, �rst described by Alos Alzheimer in 1907, it
is characterized by neuro�brillary plaques and “tangles” in
the brain. �e extracellular accumulation of amyloid beta
proteins in the neuritic plaques is one of the hallmarks of
AD (Ariga, Miyatake, & Yu, 2010). �e variation in the
clinical presentation of the disease depends on the area of
the brain that is a�ected. Classic features of AD include pro-
gressive loss of memory, deterioration of language and other
cognitive functions, decline in the ability to perform activi-
ties of daily living (ADL), and changes in personality and
behavior and judgment dysfunction (Castellani, Rolston, &
Smith, 2010). Mild cognitive impairment (MCI) represents
a transitional state between healthy aging and dementia and
is characterized by cognitive impairment out of proportion
to the age of the individual yet the individual does not meet
the criteria for dementia (Yanhong, Chandra, & Venkitesh,
2013). Incidence rates of MCI are 51 to 76.8 per 1,000
person-years with a higher incidence in advanced age, lower
education, and hypertension (Luck, Luppa, Briel, & Riedel-
Heller, 2010). About 35% of MCI patients progress to AD,
with an annual conversion rate of 5% to 10% (Mitchell,
2009). Cerebrospinal �uid (CSF) biomarkers’ performance
is the most convenient test predicting conversion yet it
remains suboptimal (Ferreira et al., 2014).
VaD, sometimes referred to as vascular cognitive
impairment (VCI) and previously known as multi-infarct
dementia (MID), refers to dementia resulting from cere-
brovascular disease. It is the second most common cause
of dementia among older adults and represents approxi-
mately 20% of all cases of dementia in the United States
(Román, 2003). �e link between AD and VaD is strong
yet not entirely clear (de la Torre, 2012). �ere are many
types of VaD and lumping them under a single rubric
causes some diagnostic confusion (Kirshner, 2009). �e
onset of VaD is usually more acute than AD and the
diagnosis of VaD is based on the association between a
cerebrovascular event and the onset of clinical features of
dementia, including evidence of focal de�cits, gait distur-
bances, personality and mood changes, and impairments
in executive function. As compared with AD, memory
may not be impaired or is more mildly a�ected. It is not
uncommon that AD and VaD pathology coexist and this,
often referred to as a mixed dementia, is likely to increase
as the population ages (Langa, Foster, & Larson, 2004).
DLB accounts for about one in 25 diagnosed cases of
dementia (Vann Jones & O’Brien, 2014). DLB is a neu-
rodegenerative dementia that results when Lewy bodies
form in the brain. Lewy bodies are pathological aggrega-
tions of alpha-synuclein found in the cytoplasma of neurons
(McKeith et al., 2003). Clinical features include cognitive
and behavioral changes in combination with features of
parkinsonism. Disorders of executive function occur early.
Hallucinations, visual–spatial disturbances and sleep disor-
ders are prominent. Rigidity and unsteady gait are common.
Many (but not all) patients with PDD develop a dementia
years after the motor symptoms appear. Distinctions have
been made clinically between DLB and the dementia associ-
ated with PDD based on the sequence of the appearance of
symptoms over the time course. In PDD, motor symptoms
precede cognitive impairment, while DLB begins with �uc-
tuations in cognition (Mayo & Bordelon, 2014). DLB and
PDD may represent the same pathological process along a
disease spectrum (Hanson & Lippa, 2009).
FTD, with a prevalence of 15 per 100,000, refers to a
group of progressive brain diseases with clinical manifes-
tations dominated by behavioral changes and/or impair-
ments in language (Riedl, MacKenzie, Forsti, Kurz, &
Diehl-Schmid, 2014). A growing body of evidence indi-
cates that FTD and amyotrophic lateral sclerosis (ALS)
share some clinical, pathological, and molecular features
as part of a common neurogenerative spectrum disorder
(Gascon & Gao, 2014).
�e National Alzheimer’s Project Act of 2011 man-
dates a national plan to address AD and related demen-
tias (speci�cally VaD, mixed dementia, DLB, and FTD;
Montine et al., 2014).
Goals of Assessment
Early identi�cation of cognitive impairment is the most
important goal in assessment. Cognitive impairment result-
ing from conditions like dementia, delirium, or depression
represents critically serious pathology and requires urgent
assessment and tailored interventions. Yet, diminished or
altered cognitive functioning is often perceived by health
care professionals as a normal consequence of aging and
opportunities for timely intervention are too often missed
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16: Dementia: A Neurocognitive Disorder  235
(Milisen, Braes, Fick, & Foreman, 2006). Although distinc-
tions have been made comparing the clinical features of the
common cognitive impairments associated with delirium,
dementia, and depression, this is di�cult to do clinically
because these conditions often coexist and older adults can
demonstrate atypical features in any of these conditions.
�e second most important assessment goal is to
identify a potentially reversible primary or contributing
cause of a cognitive impairment. �e common causes of
reversible cognitive impairment (delirium) in the older
adult are covered in Chapter 17, “Delirium: Prevention,
Early Recognition, and Treatment.”
History Taking
Complaints from the patient or observations made by oth-
ers of memory loss, problems with decision making and/or
judgment, or a decline in function in an activity of daily
living should alert the health care professional that a pro-
gressive form of dementia might exist. Collecting an accu-
rate history is the cornerstone to the assessment process,
yet this obviously is a challenge in the individual present-
ing with cognitive impairment. �e assessment domains
covered in history taking include functional, cognitive,
and behavioral queries and observations. �e history-
taking process involves �rst interviewing the patient fol-
lowed, perhaps, by clarifying, elaborating, and validating
information with the family or others familiar with the
capabilities and expressions of the patient. An informant
questionnaire on cognitive decline can also provide utility
with the commonly used tool being the Informant Ques-
tionnaire on Cognitive Decline in the Elderly (IQCODE).
Although the accuracy is reasonable its use alone may result
in misdiagnosis or false reassurance (Quinn et al., 2014),
underscoring the need for a comprehensive evaluation.
Even when a diagnosis of dementia has been made, it
is often not communicated well across care settings. �e
easiest way to increase recognition of dementia in older
hospital patients is to add the items “severe memory prob-
lems,” “Alzheimer’s disease,” and “dementia” to the list of
diseases and conditions patients and families are routinely
asked about on intake forms and in intake interviews.
Functional Assessment
Dementia is characterized by deterioration in the ability
to perform ADL. Because cognitive assessment can be
embarrassing and/or threatening it may be more respectful
to initiate the conversation around the patient’s functional
domain. Asking the patient to elaborate on his or her func-
tional abilities in ADL as well as instrumental activities
of daily living (IADL) and eliciting any identi�ed decline
with speci�ed chronology can provide some insight. �e
reader is referred to Chapter 6, “Assessing Cognitive Func-
tion” for a general approach and tools for functional assess-
ment. Several functional tools have been tested speci�cally
in individuals with dementia.
�e Functional Activities Questionnaire (FAQ) is an
informant-based measure of functional ability and has been
recognized for its ability to discriminate early dementia.
An informant, typically the primary caregiver, is asked to
rate the performance of the patient in 10 di�erent activi-
ties. �e Functional Assessment Staging Test (FAST) has
been used to e�ectively discriminate among normal cogni-
tion, MCI, and dementia and has proven to be useful in
measuring functional performance (Rikkert et  al., 2011;
Teng et  al., 2010). �e Alzheimer’s Disease Cooperative
Study (ADCS)–ADL inventory is a speci�c functional tool
used primarily in clinical drug trials to assess and monitor
patients with moderate to severe AD (Galasko et al., 1997).
Clinical studies using this scale have indicated that cholines-
terase inhibitors o�er an e�ective approach to treating func-
tional decline in certain forms of dementia (Potkin, 2002)
and lower scores on ADCS-ADL are predictive of nursing
home placement (Miller, Schneider, & Rosenheck, 2011).
�e patient’s daily caregiver is asked to rate the older adult’s
usual performance on the more basic measures of function
over the previous month to identify progression of func-
tional decline. It has been recognized that individuals with
a frontotemporal behavioral-variant form of dementia may
have greater functional impairment than those with other
forms of dementia (Lima-Silva, Bahia, Nitrini, & Yassuda,
2013). In addition to looking for potential treatments this
rating helps to provide an explanation to the patient and
family for advance care planning while the patient is still
capable of decision making. As technology continues to
advance, the manually based functional assessments may be
replaced by technology-based ones (Lowe et al., 2013).
Cognitive Assessment
�e cognitive domain is assessed as part of a broader men-
tal status evaluation, the components of which are listed in
Table 16.1. Although some of the parameters of a mental
status evaluation (such as memory or cognition) might be
measured with a standardized tool, such as the Mini-Mental
State Exam (MMSE), others require speci�c inquiry or direct
or indirect observation by the health care professional and/
or caregiver. �e measure of mood is totally subjective and
is based on self-report status. �e evaluation always provides
the opportunity to identify sensory impairments (vision and
hearing loss), which can further impact cognition, function,
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236  III: Clinical Interventions
and behavior. �ere are a variety of tools for assessing cogni-
tive impairment, some more sensitive to mild dementia and
others to moderate to severe dementia.
�e gold standard of tools that measure cognition is the
MMSE, which was developed over 30 years ago (Folstein,
Folstein, & McHugh, 1975). Used extensively in clinical
trials as well as in a variety of clinical settings, it is rela-
tively easy to administer and score and can be used to assess
cognitive changes over time. �e annual rate of decline
on the MMSE in AD is 3.3 points annually (Han, Cole,
Bellavance, McCusker, & Primeau, 2000). �e MMSE has
established validity and reliability although concerns con-
tinue to be expressed by clinicians that it is time-consuming
and in some circumstances the relevancy of selected ques-
tions has been raised. �e MMSE score is strongly related
to education with high false-positive rates for those with
little education; predictive power is also signi�cantly in�u-
enced by language (Parker & Philp, 2004). It is insensitive
to executive dysfunction and has been criticized for a lack
of sensitivity in detecting early or mild dementia (Liefer,
2003). As has been suggested with other measures of cogni-
tive testing, the MMSE may have a cultural bias (Manly &
Espino, 2004). Clinicians must remain aware that a high
score on the MMSE does not rule out cognitive decline or
the possibility of dementia particularly in high-functioning
individuals with cognitive complaints (Manning, 2004).
�e tool is no longer in the public domain and copyright
permission must be secured. A tool with comparable sensi-
tivity and speci�city for detecting dementia is the St. Louis
University Mental Status Exam (SLUMS) and it is available
for free (Tariq, Tumosa, Chibnall, Perry, & Morley, 2006).
Instruments, such as the Mini-Cog (Borson, 2003),
Memory Impairment Screen (Buschke, 1999), and General
Practitioner Assessment of Cognition (Brodaty, 2002), have
all been recognized for utility, whereas the Clock Draw test
(CDT, Shulman, 2000) and newer instruments, such as
the Montreal Cognitive Assessment (MoCA, Nasrredine et
al., 2005), have greater sensitivity, address frontotemporal
executive function and have less educational and cultural
bias (Ismail, Rajji, & Shulman, 2010). Unlike the more
language-based tools described earlier, the CDT assesses
cognition focused on executive function. A systematic
review of the literature identi�ed the CDT’s usefulness in
predicting future cognitive impairment (Peters & Pinto,
2008). Scoring is based on the ability to free-hand draw
the face of a clock, insert the hour numbers in the appro-
priate location, and then set the hands of the clock to the
time designated by the examiner. �e CDT is strongly cor-
related with executive function (i.e., the ability to execute
complex behaviors and to solve problems) and is useful in
the detection of mild dementia (Peters & Pinto, 2008). It
also correlates moderately with driving performance, as the
CDT score drops the number of driving errors increases
(Freund, Gravenstein, Ferris, Burke, & Shaheen, 2005;
Freund, Gravenstein, Ferris, & Shaheen, 2002).
A clinically useful tool that combines the CDT with
measures of cognition (three-word recall) is the Mini-
Cognitive (Mini-Cog; Borson, Scanlan, Brush, Vitaliano,
& Dokmak, 2000). �e Mini-Cog detected cognitive
impairment in a community sample of predominately
ethnic minority better than primary care physician assess-
ment (84% vs. 41%) particularly in milder stages of the
disease (Borson, Scanlan, Watanabe, Tu, & Lessig, 2005).
A systematic review of the Mini-Cog for screening
for dementia in primary care demonstrated that it was
brief; easy to administer; clinically acceptable and e�ec-
tive; and minimally a�ected by education, gender, and
ethnicity (Milne, Culverwell, Guss, Tuppen, & Whelton,
2008) with psychometric properties similar to the MMSE
(Brodaty, Low, Gibson, & Burns, 2006).
Behavioral Assessment
Behavioral changes occur both in early-stage and through-
out dementia (Kilik et al., 2008), and are also seen in MCI;
commonly these include depression, anxiety, and irrita-
bility (Monastero, Mangialasche, Camarda, Ercolani, &
Camarda, 2009). Regular assessment and monitoring can
help identify the triggers of disruptive behavior and early
manifestations of the behavior. Timely interventions that
TABLE 16.1
Components of Mental Status Evaluation
State of consciousness: quality or state of awareness
General appearance and behavior: appropriately groomed
and interactive
Orientation: person, place, time
Attention and concentration: ability to attend and
Memory: ability to register, recall, retain
Judgment and insight: ability to make appropriate decisions
Executive control functions: ability to abstract, plan,
sequence, and use feedback to guide performance
Visual–spatial function: ability to mentally manipulate a �gure
Speech and language: ability to communicate ideas and
receive and express a message
Thought content: presence of delusions, hallucinations
Mood and affect: how individual feels most days and at a given
moment and the appropriateness of behavior demonstrated
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16: Dementia: A Neurocognitive Disorder  237
result in de-escalation of the behavior can help decrease
the level of distress experienced both by the patient and
caregiver. Behavioral management can help maintain
functionality and safety. Commonly demonstrated behav-
iors are those associated with agitation and psychosis.
Asking the patient about levels of restlessness, anxiety,
and irritability is important, as at times these emotional/
behavioral states occur even earlier than cognitive changes.
Aggression, wandering, delusions and hallucinations, and
resistance to care are manageable with nonpharmacologi-
cal and pharmacological treatment options.
�e literature on the link between psychosis and
aggression in people with dementia is mixed (Shub,
Ball, Abbas, Gottumukkala, & Kunik, 2010). �e
Neuropsychiatric Inventory (NPI, Cummings, 1994)
measures frequency and severity of psychiatric symptoms
and behavioral manifestations in individuals with demen-
tia. �e NPI takes about 10 minutes to administer during
which the caregiver is asked screening and probing ques-
tions related to the presence and degree of behaviors such
as agitation, anxiety, irritability, apathy, and disinhibition.
�e NPI also includes a measure of caregiver stress. It has
established validity and reliability though it does not dis-
criminate between disorder types (Lai, 2014).
Because as many as 50% of individuals with demen-
tia have coexisting depressive symptoms (Lee & Lyketsos,
2003), it is important to conduct an adjunctive assess-
ment of depression. Recognizing depressive symptoms in
older adults is challenging and using an interviewer-rated
instrument is recommended in addition to using clinical
judgment (Onega, 2006). �e Geriatric Depression Scale
(GDS) is a screening instrument that takes only a few
minutes to administer and is discussed along with appro-
priate depression-management strategies in detail in a
Chapter 15, “Late-Life Depression.”
Referral of the patient to a neuropsychologist for more
extensive neuro psychological testing is often indicated
in order to provide more speci�c diagnostic information
associated with neurodegenerative disease states and areas
of brain dysfunction. �is kind of assessment can identify
subtle cognitive impairments in higher functioning indi-
viduals, distinguish MCI from dementia, and can provide
direction and support for care providers and the family
(Adelman & Daly, 2005).
Physical Examination and Diagnostics
Once the functional, cognitive, and behavioral domains in
progressive dementia have been established through history
taking of the patient and caregiver, a thorough review of sys-
tems is undertaken followed by the physical examination.
�e history-taking process narrows the di�erential diag-
nosis of reversible and irreversible causes for dementia. A
thorough neurological and cardiovascular examination will
help to specify the etiology of a single type or combined
dementia, which will direct the need for laboratory and
imaging tests. Cardiovascular �ndings, such as hyperten-
sion, arrhythmias, extra heart sounds or murmurs, along
with focal neurological �ndings, such as weakness and
sensory de�cit, may favor a diagnosis of VaD, pathologi-
cal re�exes, gait disorders, and abnormal cerebellar �ndings
that may be indicative of AD, and parkinsonian signs that
might indicate dementia associated with either Lewy bod-
ies or PDD (Kane, Ouslander, Abrass, & Resnick, 2013).
�ere are no speci�c laboratory tests for the diagno-
sis of progressive dementia other than those that can pri-
marily indicate a potentially reversible or contributing
cause (see Table 16.1 and Chapter 17). �e American
Academy of Neurology (AAN) recommends two speci�c
laboratory tests (thyroid function and B
) in the ini-
tial evaluation of suspected dementia (Knopman et al.,
2001). �e AAN similarly recommends that all patients
with suspected dementia have an MRI study or non-
contrast CT as part of the initial workup. Once demen-
tia has become clinically relevant and a cause apparent,
there is no further diagnostic yield a�orded by imaging.
Caregiver Assessment
It is important to remember that the caregiver is a patient
too in that he or she su�ers, as does the patient with demen-
tia. Caregiver need and burden refer to the psychological,
physical, and �nancial burden associated with caregiving.
Caregivers are at risk of depression, physical illness, and anx-
iety (Cooper, Balamurali, & Livingston, 2007; Schoenmak-
ers, Buntinx, & Delepeleire, 2010). Behavioral problems are
determinants of burden yet feeling con�dent and positive
self-e�cacy can diminish caregiver burden (van der Lee,
Bakker, Dunenvooden, & Droes, 2014). �e Zarit Burden
Interview (ZBI) can be used to identify the degree of burden
experienced by the caregiver. �e ZBI is a four-item screen-
ing followed by an additional 12 items; the test has good
reliability and validity (Higginson, Gao, Jackson, Murray,
& Harding, 2010). Administration of this tool to a com-
munity-dwelling caregiver can indicate the extent of impact
caregiving has on the caregiver’s health, social and emotional
well-being, and �nances. �e Modi�ed Caregiver Strain
Index (CSI) is another tool that has been used to identify
families with caregiving concerns (Onega, 2008). �ere is
a growing body of literature that describes the relationship
between people with dementia and the family members
who care for them (Ablitt, Jones, & Muers, 2009).
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238  III: Clinical Interventions
�ere is no cure for progressive dementia. �e manage-
ment of individuals with dementia requires pharmacologi-
cal and nonpharmacological interventions.
Pharmacological Interventions
�e goals of pharmacological therapy in dementia include
preserving what the disease destroys in cognitive and func-
tional ability, minimizing what the disease imposes in the
way of behavior disturbances, and slowing the progres-
sion of the disease e�ects brought on by the destruction
of neurons (Geldmacher, 2003). Nurses, regardless of
whether they are the prescribers of drug therapy, need to
be informed about the variety of drugs used in managing
dementia and the evidence supporting their pharmacologi-
cal approaches. Although there is substantial evidence that
adults with mild to severe AD would bene�t from drug
therapy, there are no solid data in support for drug therapy
for individuals with other forms of dementia (Schwarz,
Froelich, & Burns, 2012).
Acetyl cholinesterase inhibitors (AChEIs) are the main-
stay of treatment in AD. �ree are currently available in the
United States: donepezil hydrochloride (Aricept), rivistig-
mine tartrate (Exelon), and galantamine hydrobromide
(Razadyne) with tacrine hydrochloride (Cognex)—the oldest
and less favored drug taken o� the market in 2013 because
of its adverse e�ect on the liver and multiple daily dosing. A
combination drug, memantine/donepezil (Namzaric), is also
available. Cognitive improvements in patients with mild to
moderate AD have been shown for all three of the AChEIs
agents available in the United States (Tan et al., 2014). �e
acetyl cholinesterase inhibitors are safe and well tolerated;
however, they may have gastrointestinal side e�ects (nausea,
anorexia, and diarrhea). �ere is insu�cient evidence at this
time that pharmacological therapy for dementia can improve
the quality of life for the patient and the caregiver and delay
nursing home placement.
Memantine (Namenda), approved for moderate to
severe dementia, has a di�erent mechanism of action than
the acetyl cholinesterase inhibitors. �is N-methyl-�-
aspartate receptor antagonist has neuroprotective e�ects
that prevent excitatory neurotoxicity. Individuals with
AD have improved cognition and behavior on this drug
(McShane, Areosa Sastre, & Minakaran, 2006). Side
e�ects of memantine, although uncommon, include diar-
rhea, insomnia, and agitation. In combined administration
of cholinesterase inhibitors with memantine the research is
mixed. Some studies (Atri et al., 2013; Riepe et al., 2007)
demonstrated increased e�cacy in advanced AD as com-
pared to cholinesterase inhibitors alone, whereas another
demonstrated that the combined treatment had no bene�t
(Howard et al., 2012).
Pharmacological Therapy
for Problematic Behaviors
Behavior changes are common in the mid- to later stages
of progressive dementia and although nonpharmacologi-
cal interventions are preferred, supplementation with a
tailored drug regimen is sometimes necessary. Psychotro-
pic medications, primarily antipsychotics, can be admin-
istered to help the individual regain control and be less
disruptive—positive outcomes for the caregiver as well as
the patient. Drugs must be prescribed in the lowest e�ec-
tive dose for the shortest amount of time. �e patient
needs to be closely monitored for e�ectiveness and adverse
side e�ects. Psychotropic medications have a high risk of
adverse drug events and this is covered in Chapter 20,
“Reducing Adverse Drug Events.”
Psychotropic therapy for di�erent behaviors is always
short term. Once the target symptoms are relieved or
abbreviated, then consideration must be given to terminate
therapy. Health care professionals and families are often
hesitant to stop antipsychotics fearing a return or worsen-
ing of neuropsychiatric symptoms, although the literature
re�ects that these can generally be withdrawn without det-
rimental e�ects (Declercq et  al., 2013). Long-term psy-
chotropic drug therapy should be considered only if the
symptoms reoccur. Psychotic symptoms (such as delusions
and hallucinations) frequently occur in the later stages of
progressive dementia and are often associated with agita-
tion and aggression (Ropacki & Jeste, 2005). �e conven-
tional antipsychotic, haloperidol (Haldol), has been used
for decades and remains the most commonly used drug
for rapid tranquilization and control of psychotic symp-
toms in individuals with dementia. A Cochrane Review
(Lonergan, Luxenberg, & Colford, 2002) validated the
useful role of haldol in managing aggression but did
not �nd evidence for its role in managing agitation for
patients with dementia. �e side e�ects of conventional
antipsychotics are considerable and include extrapyrami-
dal symptoms, tardive dyskinesia, sedation, orthostatic
hypotension, and falls.
Although not FDA approved, the atypical anti-
psychotics are often prescribed for use in patients with
dementia. Evidence indicates that they may bene�t people
with dementia but the risks of adverse events (cardiovas-
cular, extrapyramidal symptoms) may outweigh the ben-
e�t, especially with long-term treatment (Maher et  al.,
2011). Agents available on the market include risperidone,
olanzapine, quetiapine, ziprasidone, aripiprazole, and
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16: Dementia: A Neurocognitive Disorder  239
paliperidone. �ere are little to no published data on the
e�cacy and safety of the last three drugs listed. Additional
research is needed to determine when and how to use psy-
chotropic medications to address behaviors in individuals
with dementia. Other drug categories are sometimes used
to control behavioral symptoms.
Benzodiazepines (lorazepan, oxazepan, alprazolam)
are sometimes used to manage agitation and aggression;
however, the risk–bene�t ratio is often unsatisfactory.
Although the benzodiazepines may be useful in rapidly
sedating the agitated patient with dementia, the potential
for falls and worsening of cognition limit long-term use.
Again, nonpharmacological interventions to treat behav-
ioral manifestations of distress are preferred.
Although antidepressants (Seitz et  al., 2011) and
anticonvulsants are sometimes used to treat agitation in
dementia, there is insu�cient evidence to support their
use. Behavioral disturbances should not necessarily be
interpreted as depression.
Supplemental Drugs
Anti-in�ammatory drugs and estrogen; herbals, such as
gingko; and vitamins, such as B
, folate, and vitamin E—
although sometimes touted and commonly used—have
no proven e�cacy for dementia although some isolated
studies have demonstrated a bene�t. Dementia associ-
ated with VaD requires appropriate control of hyperten-
sion, hyperlipidemia, and aspirin therapy. Parkinsonism
(rigidity), seen with DLB, may bene�t from dopaminergic
therapy. Selective antidepressants and amphetamines may
be e�ective in reducing the behavioral symptoms in FTD
(Nardell & Tanjo, 2014).
Nonpharmacologic Interventions
Nonpharmacological strategies, including those from the
cognitive, behavioral, and environmental domains, in
combination with sta� support and education are e�ec-
tive. Physical/functional, environmental, psychosocial,
behavioral, and end-of-life (EOL) care interventions are
discussed as follows.
Physical/Functional Interventions
Maintaining physical and functional well-being of the
individual with progressive dementia facilitates indepen-
dence, maintains health status, and can ease the caregiv-
ing burden. Interventions include adequate nutrition and
hydration, regular exercise, maintenance of ADL, proper
rest and sleep, appropriate bowel and bladder routines,
proper dental hygiene and care, and current vaccinations.
As comorbidities are common (Lyketsos et  al., 2005)
regular assessment, vigilant monitoring, and aggressive
management of acute and chronic conditions are neces-
sary. Vehicular-driving safety might need to be examined
as recent evidence indicates that individuals with demen-
tia pose a risk in driving safety (Man-Son-Hing, Marshall,
Molnar, & Wilson, 2007). �ere is insu�cient evidence to
support or refute the bene�t of neuropsychiatric testing or
intervention strategies for drivers with dementia (Iverson
et al., 2010).
Environmental Interventions
A specialized ecological model of care, which facilitates
interaction between the person and environment in a
more homelike atmosphere, has proven to be bene�cial
for individuals with dementia. �is model a�ords greater
privacy, encourages meaningful activities, and permits
more choice than the traditional model of care. It also
demonstrates that individuals with dementia experience
less decline in ADL and are more engaged with the envi-
ronment with no measurable di�erences found in cogni-
tive measures, depression, or social withdrawal (Reimer,
Slaughter, Donaldson, Currie, & Eliasziw, 2004). A study
examining social engagement of residents before and
after conversion to a household model (culture change)
was highly signi�cant (Morgan-Brown, Newton, &
Ormerod, 2013).
A systematic review reported inclusive results and
suggested that more research is needed with regard to the
use of bright light in fostering better sleep and reducing
behavior problems in dementia (Forbes et al., 2009). �e
use of aromatherapy to reduce disturbed behavior, pro-
mote sleep, and stimulate motivation also shows promise
but needs more study (�orgrimsen, Spector, Wiles, &
Orrell, 2003). Manipulation of the environment (alarms,
circular hallways, visual, or structural barriers) to mini-
mize wandering has not been conclusively demonstrated
to be e�ective (Futrell & Melillo, 2002). �ere is a lack of
robust evidence supporting nonpharmacological interven-
tions for wandering (Robinson et al., 2007).
Psychosocial Interventions
Mental and social engagement is important to the well-
being of all older adults. Meaningful activity and involve-
ment are no less important in individuals with dementia.
Although the e�ectiveness of counseling or procedural
memory stimulation is not supported in mild-stage demen-
tia, reality orientation does appear to be e�ective (Bates,
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240  III: Clinical Interventions
Boote, & Beverley, 2004). �e evidence suggests that cog-
nitive therapy is more bene�cial than no therapy at all but
it may be patient speci�c (Carrion, Aymerich, Bailles, &
Lopez-Bermejo, 2013; Woods, Aguirre, Spector, & Orrell,
2012). Validation therapy, based on caregiver acceptance of
the reality of the person with dementia’s experience, may be
of value but the evidence is lacking (Neal & Barton Wright,
Recreational therapies, including music, have been
shown to reduce psychological symptoms in dementia
with limited e�cacy and questionable duration of action
(O’Connor, Ames, Gardner, & King, 2009) and more
research is needed to explore the e�ects of music therapy
on the behavior and well-being of individuals with demen-
tia (Wall & Du�y, 2010). A growing body of evidence
shows that individuals with dementia enjoy music but
there is little scienti�c investigation within this area (Baird
& Samson, 2015; Samson, Clement, Narme, Schiaratura,
& Ehrle, 2015). In addition to music, other cultural arts
(poetry, storytelling, dance) have re�ected positive social
and behavioral changes though there are some study
design issues that limit inclusion in a systematic review
(de Medeiros & Basting, 2014). Structured nonpharma-
cological short-term occupational therapy interventions
were more useful in improving apathy in patients with
dementia than activities of the patient’s choice (Ferrero-
Arias et al., 2011).
Support groups, counseling, and education for indi-
viduals with early AD and their caregivers are essential.
Caregivers often experience physical, �nancial, social, and
emotional losses and providing information through a
structured education program and engaging them in the
care-planning process is essential (Battaglini, 2013). Areas
for caregiver education are detailed in Table 16.2.
Behavioral Interventions
Behavioral and psychosocial symptoms of dementia are
common with every form of progressive dementia, par-
ticularly in the moderate stage. �e three most trouble-
some symptoms are agitation, aggression, and wandering.
Problematic behaviors that occur during meals or bathing
can be particularly challenging. It is important to recog-
nize and realize that any new behavior could be a sign of
an acute illness or an environmental in�uence. Unrecog-
nized pain can cause disruptive behavior. �e Progressively
Lowered Stress �reshold (PLST) is a framework to opti-
mize function, minimize disruption, and help the care-
giver (M. Smith, Hall, Gerdner, & Buckwalter, 2006). �e
PLST model increases the positive appraisal and decreases
the negative appraisal of the caregiving situation (Stolley,
Reed, & Buckwalter, 2002) and helps the caregiver man-
age the aggressive behaviors demonstrated in AD (Cheung,
Chien, & Lai, 2011; Lindsey & Buckwalter, 2009). By
adapting the environment and routines, interventions are
designed to help the patient with dementia use his or her
functional skills and minimize potentially triggering reac-
tions. �ere are six essential principles of care in the PLST:
1. Maximize safe function: Use familiar routines, limit
choices, provide rest periods: reduce stimuli when stress
occurs, and routinely identify and anticipate physical
stressors (pain, urinary symptoms, hunger, or thirst).
2. Provide unconditional positive regard: Respectful con-
versation, simple and understandable language, and
nonverbal expressions of touch.
3. Use behaviors to gauge activity and stimulation:
Monitor for early signs of anxiety (pacing, facial gri-
macing) and intervene before behavior escalates.
4. Teach caregivers to “listen” to the behaviors: Monitor
the language pattern (repetition, jargon) and behaviors
(rummaging) that might be showing how the person
reduces stress when needs are not being met.
5. Modify the environment: Assess the environment to
assure safe mobility and promote way-�nding and ori-
entation through cues.
6. Provide ongoing assistance to the caregiver: Assess and
address the need for education and support.
Advance Planning and EOL Care Interventions
Advance planning and providing directives for care are
important in guiding the types of interventions used at the
end of life and can decrease the caregiver stress in proxy
decision making. Advance directives in cases of demen-
tia have been a debated subject for although advance
TABLE 16.2
Education Content for Caregivers
Information about the disease and its progression
Strategies to maintain function and independence
Preservation of cognitive and physical vitality in dementia
Maintaining a safe and comfortable environment
Giving physical and emotional care
Communicating with the individual with dementia
Managing behavioral problems
Advance planning: health care and �nances
Caregiver survival tips
Building a caregiver support network
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16: Dementia: A Neurocognitive Disorder  241
directives are considered valid, they are marginally e�ec-
tive. As many as 90% of Americans with dementia will
be institutionalized before death (G. E. Smith, Kokmen,
& O’Brien, 2000)

making this environment in particu-
lar an important focus for EOL care. �ere is a lack of
research published on EOL care in the nursing home and
most of it is descriptive (Oliver, Porack, & Zewig, 2004).
�e end stage of AD may last for several years and fre-
quently distressing signs and symptoms occur at this time.
Nursing home patients and their families want physicians
more involved in EOL care, to acknowledge the presence
of the patient and caregiver, and provide guidance (Fosse,
Schaufel, Reiths, & Malterud, 2014). See Chapter  39
“Advance Care Planning” for a fuller discussion.
Dementia itself or associated conditions can cause
physical symptoms, such as poor nutrition, urinary incon-
tinence, skin breakdown, pain, infection, shortness of
breath, fatigue, di�culty in swallowing, choking, and gur-
gling, in addition to the behavioral symptoms mentioned
earlier. �ere is no acceptable standard treatment for the
consequences of advanced dementia and where guidelines
do exist there is minimal palliative care content. Aggressive
treatments, such as antibiotics, tube feedings, psychotropic
drugs, and physical restrains to address problematic behav-
iors, appear to be prevalent although there is no substantial
evidence that this approach is e�ective in end-stage demen-
tia and that prognosis and life expectancy are improved
by these strategies (Evers, Purohit, Perl, Khan, & Marin,
2002). Measuring quality of care at the end of life for those
with dementia poses signi�cant challenges because of the
limitations in subjective reporting and therefore relies on
the caregiver’s analysis of cues to monitor the patient’s con-
dition and experience (Volicer, Hurley, & Blasi, 2001). In
spite of the clear recognition that signi�cant improvements
in EOL care for those with dementia is needed (Scherder
et al., 2005), there is a lack of systematic evidence on how
to approach palliative care for this population (Sampson,
Ritchie, Lai, Raven, & Blanchard, 2005).
Mrs. P is an 85-year-old Caucasian woman brought
into the primary care clinic by her daughter for a geri-
atric consultation. She has a 4-year history of decline
in cognitive impairment that began with memory loss
and impaired judgment, which appears to be worsen-
ing; she is now experiencing some behavioral problems.
Mrs. P is high school educated, widowed for 10 years,
and is a retired short-order cook. She currently lives
with her daughter, son-in-law (both work full time),
and grandson.
Her primary care physician completed a demen-
tia workup at the time the symptoms appeared 4 years
ago and started her on donepezil, which was discon-
tinued within a few days because of gastrointestinal
side e�ects. �e daughter reports she is allergic to it.
Mrs. P recently had paranoid ideation in which she
accused her 15-year-old grandson of listening in on her
phone conversations and taking some money from her
purse. Her daughter reports that Mrs. P has always had
“a short fuse” and now gets agitated easily. “She called
me a moron and even took a swing at me the other day
when I told her she smelled bad and needed to take a
Mrs. P performs her own personal hygiene
though she needs reminders and cueing at times;
she is continent. She does not perform any IADL
(e.g., cooking, shopping) and it was unclear whether
she truly was no longer capable of performing these
functions or no longer had the opportunity or desire
to do them. Mrs. P reports no desire to eat and had
a weight loss resulting in a change in at least three
clothing sizes that has occurred slowly over the past
few years. She reports that she has always been over-
weight and is proud of this accomplishment. �e
daughter says she has tried to get her to eat by serving
food that she likes but she just “plays with the food”
pushing it around on her plate and has been seen
sneaking it to the dog while at the table. When asked
about her mood she becomes tearful and says, “I feel
lonely; no one cares about me anymore.” Mrs. P says
she hates to be alone and that the family “just come
and goes—they never talk with me.” She used to take
an evening walk in the neighborhood but now that
she lives with her daughter she is unfamiliar with
and fearful of her surroundings. Her MMSE score
is 18/30 with de�cits in memory, calculation, and
ability to copy the intersecting pentagons. She scores
10/15 on the GDS.
Past medical history includes thyroidectomy, left
cataract extraction, cholecystectomy, and hysterectomy
for benign disease. Her daughter thinks that Mrs. P
may have been on antihypertensives in the past. �e
only medication Mrs. P takes at present is for her thy-
roid but neither she nor her daughter know the name
of the drug.
On physical examination Mrs. P is afebrile; blood
pressure is 132/70, and she is about 10 pounds below
her ideal body weight. Mrs. P is alert, cooperative,
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242  III: Clinical Interventions
It is important that health care professionals identify cog-
nitive impairments in older adults early and di�erentiate
a progressive from a reversible etiology, such as delirium.
Comprehensive assessment, monitoring, and pharmaco-
logical and nonpharmacological management of physical,
functional, cognitive, and behavioral problems are impor-
tant both in initial identi�cation and in the ongoing care
of the individual with progressive dementia. Education
and support of the family and professional caregiver are
essential. It is di�cult to identify clearly what constitutes
quality of life for the individual with progressive dementia,
what interventions enhance this quality, and how this is
accomplished. Overall, there is limited evidence in geron-
tological nursing to guide the care of older adults with
dementia. It is imperative that geriatric nurses evaluate
practice and generate new knowledge to assure best prac-
tice in the care of individuals with progressive dementia
and their caregivers.
and smiles at intervals during the examination and
has hearing loss bilaterally with clear canals; no thy-
romegaly. Cardiovascular examination reveals no mur-
mur, edema, or discolorations of the extremities. Pulses
are strong throughout. �ere are no focal neurological
symptoms. Gait is slow but steady. She has full range
of motion but her muscle tone and strength are dimin-
ished in both upper and lower extremities. Breasts are
free of masses and abdomen is soft, nontender with no
organ enlargement.
A diagnosis of depression and progressive demen-
tia of the Alzheimer’s type is made and she is started on
the combination of donepezil and mementine, both to
be titrated slowly. Additional information from Mrs.
P’s primary care physician will be consulted about
potential lab work and diagnostic studies, including
thyroid function. �e need for a nutritional and hear-
ing evaluation will be explored. Antidepressant ther-
apy may be considered at a later date. Health teaching
and additional resource information is provided to the
Depression is not uncommon in those with a progres-
sive dementia. Severe anxiety, agitation, and aggres-
sion can occur; tearfulness and decreased appetite
with weight loss may also be present. Using the PLST
model, the nurse focuses on teaching the daughter to
recognize triggers and prodromal signs of increasing
anxiety and intervene appropriately when anxiety and
agitation occur. Strategies are emphasized in each of
the PLST principles of care: maximize safe function,
provide unconditional regard, use behaviors to gauge
activity and stimulation, “listen” to the behaviors and
modify the environment. Less confrontational lan-
guage and behaviors are emphasized in approaches
and interactions with Mrs. P. �e daughter is also pro-
vided with speci�c contact information for the geriatri-
cian’s o�ce as well as the local and national resources
available through the Alzheimer’s Association and the
Alzheimer’s Disease Education and Referral Center
(ADEAR). Instructions include dietary strategies to
increase nutritional density and an exploration of ways
to increase social engagement and exercise while assur-
ing safety. If available in the area, Meals on Wheels,
Friendly Visitors, and Home Safety Assessment might
be of bene�t. Speci�c medication instructions with
particular emphasis on how to use the titration packet
are provided, with the recommendation to coadmin-
ister with food to reduce the likelihood of gastroin-
testinal side e�ects. It was explained that what Mrs. P
experienced earlier was likely medication intolerance
not an allergy and administering with food should
help. �e nurse plans a follow-up phone call for the
next day and schedules a follow-up medical and health
teaching appointment in 1 month to evaluate the e�ec-
tiveness of the plan of care. �e patient and family are
instructed to call or return if new or changed behav-
iors or physical symptoms develop. Caregiving has its
burdens and rewards and impacts the entire family. At
the next visit the nurse plans to have the daughter, son-
in-law, and grandson present to get their perspective
and engage them in discussion on the development of
a family-centered plan of care, including advance care
CASE STUDY (continued)
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16: Dementia: A Neurocognitive Disorder  243
Protocol 16.1: Recognition and Management of Dementia:
A Major Neurocognitive Disorder
A. Early recognition of dementing illness
B. Appropriate management strategies in care of individuals with dementia and their families
�e rapid growth of the aging population is associated with an increase in the prevalence of progressive dementias. It is
imperative that a di�erential 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.
A. De�nitions/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. �e most common forms of progressive dementia are AD, VaD, DLB, and FTD; the pathophysiology for each
is poorly understood.
4. Di�erential diagnosis of dementing conditions is complicated by the fact that concurrent disease states (i.e.,
comorbidities) often coexist.
B. Prevalence
1. Dementia a�ects about 11% of individuals aged 65 years and older.
2. Four to �ve million individuals in the United States have AD with a projected number of 13.8 million cases by 2050.
3. Global prevalence of dementia is about 44.4 million with projections of 135.5 million by 2050.
C. Risk factors
1. Advanced age
2. MCI
3. Cardiovascular disease
4. Genetics: family history of dementia, PDD, cardiovascular disease, stroke, presence of ApoE4 allele on chromosome 19
5. Environment: head injury, alcohol abuse
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. �inking: ability to organize and communicate ideas
5. Language: ability to receive and express a message
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244  III: Clinical Interventions
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 MMSE is the most commonly used test to assess serial cognitive change. �e MMSE is copy-
righted and a comparable tool, SLUMS, is in the public domain.
2. 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 FAQ and the FAST, can detect dementia. �ey are also useful
in monitoring the progression of functional decline.
2. �e 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, disinhibi-
tions, delusions, hallucinations.
2. Evaluate for depression because it commonly coexists in individuals with dementia. �e 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
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 di�erentiating irreversible from reversible forms of dementia. Two laboratory
tests speci�cally recommend in the initial evaluation are thyroid function and B
. Structural neuroimaging
with noncontrast CT or MRI scans are appropriate in the routine initial evaluation of patients with dementia.
F. Caregiver/environment
1. �e 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.
a. Elicit the caregiver perspective of patient function and the level of support provided.
b. 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 ZBI and the CSI tools.
c. Evaluate the caregiver experience and patient/caregiver relationship.
A. �e PLST framework provides a framework for the nursing care of individuals with dementia.
1. Monitor the e�ectiveness and potential side e�ects 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, �uid, 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 con�ict
that may be causing the behavior; de�ne the target symptom (i.e., agitation, aggression, wandering) and
Protocol 16.1: Recognition and Management of Dementia:
A Major Neurocognitive Disorder (continued)
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16: Dementia: A Neurocognitive Disorder  245
pharmacological (psychotropics) and nonpharmacological (manage a�ect, limit stimuli, respect space, distract,
redirect) approaches; provide reassurance; and refer to appropriate mental health care professionals as indicated.
7. Assure a therapeutic and safe environment: Provide an environment that is modestly stimulating avoiding
overstimulation, which can cause agitation and increase confusion and understimulation, which can cause
sensory deprivation and withdrawal. Use patient identi�ers (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 aides that facilitate cognition, and maintain consistency in caregivers
and approaches. Psychosocial interventions and cultural arts therapy in dementia may prove bene�cial.
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 manage-
ment; weigh the bene�ts/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 profession-
als; 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.
A. Patient outcomes: �e 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 e�ective caregiving skills; verbalize satisfaction
with caregiving; report minimal caregiver burden; are familiar with, have access to, and use available resources.
C. Institutional outcomes: �e institution re�ects 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.
A. Follow-up appointments are regularly scheduled; frequency depends on the patient’s physical, mental, and emo-
tional status and caregiver needs.
B. Determine the continued e�cacy 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.
A. American Academy of Neurology: Dementia: www.aan.com/guidelines
B. American Association of Geriatric Psychiatry: Position Statement: Principles of Care for Patients With Dementia
Resulting From Alzheimer Disease: www.aagponline.org/index.php?src=news&submenu=Tools_Resources&srctyp
C. Alzheimer’s Foundation of America: Excellence in Care: www.alzfdn.org
D. American Medical Directors Association: www.amda.com/tools/guidelines.cfm#dementia
E. American Geriatrics Society: geriatricscareonline.org
F. Geriatric Advance Practice Nurse Association: www.gapna.org/resources/toolkit-gerontology-resources-advanced-
G. Hartford Institute for Geriatric Nursing: www.hartfordign.org
Protocol 16.1: Recognition and Management of Dementia:
A Major Neurocognitive Disorder (continued)
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246  III: Clinical Interventions
AD Alzheimer’s disease
ADL Activities of daily living
CDT Clock Draw test
CSI Caregiver Strain Index
DLB Dementia with Lewy bodies
EOL End of life
FAQ Functional Activities Questionnaire
FAST Functional Assessment Staging Test
FTD Frontotemporal dementia
GDS Geriatric Depression Scale
IADL Instrumental activities of daily living
MCI Mild cognitive impairment
Mini-COG Mini-Cognitive
MMSE Mini-Mental State Exam
PDD Parkinson’s disease
PLST Progressively Lowered Stress �reshold
SLUMS St. Louis University Mental Status Exam
VaD Vascular dementia
ZBI Zarit Burden Interview
Protocol 16.1: Recognition and Management of Dementia:
A Major Neurocognitive Disorder (continued)
Alzheimer’s Association
Alzheimer’s Disease Education and Referral Center
Caregiver Action Network (formerly National Family Caregiver’s
Hartford Institute for Geriatric Nursing
Lewy Body Dementia Association
National Alliance for Caregiving
National Council of Certi�ed Dementia Practitioners
National Hospice and Palliative Care Association
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patient with suspected dementia. American Family Physician,
71(9), 1745–1750. Evidence Level VI.
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tia: Dementia statistics. Retrieved from www.alz.co.uk/research
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Boltz, M. P. R. G. F., Capezuti, E. P. R. F., Fulmer, T. T. P. R. F., & Zwicker, D. D. A. B. (Eds.). (2016). Evidence-based geriatric nursing protocols for best practice, fifth
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16: Dementia: A Neurocognitive Disorder  247
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