Application of the Nursing Process: Dementia

APPLICATION OF THE NURSING PROCESS: DEMENTIA

This section focuses on caring for clients with progressive dementia, which is the most common type. The nurse can use these guidelines as indicated for clients with dementia that is not progressive.

Assessment

The assessment process may seem confusing and compli-cated to clients with dementia. They may not know or may forget the purpose of the interview. The nurse provides simple explanations as often as clients need them, such as “I’m asking these questions so the staff can see how your health is.” Clients may become confused or tire easily, so frequent breaks in the interview may be needed. It helps to ask simple rather than compound questions and to allow clients ample time to answer.

A mental status examination can provide information about the client’s cognitive abilities such as memory, con-centration, and abstract information processing. Typically, the client is asked to interpret the meaning of a proverb, perform subtraction of figures without paper and pencil, recall the names of objects, make a complete sentence, and copy two intersecting pentagons. Although this does not replace a thorough assessment, it gives a cursory evalua-tion of the client’s cognitive abilities. It is important to remember that people with severe depression or psychosis may also be unable to perform some of these cognitive tasks correctly.

History

Considering the impairment of recent memory, clients may be unable to provide an accurate and thorough his-tory of the onset of problems. Interviews with family, friends, or caregivers may be necessary to obtain data.

General Appearance and Motor Behavior

Dementia progressively impairs the ability to carry on meaningful conversation. Clients display aphasia when they cannot name familiar objects or people. Conversation becomes repetitive because they often perseverate on one idea. Eventually, speech may become slurred, followed by a total loss of language function.

The initial finding with regard to motor behavior is the loss of ability to perform familiar tasks (apraxia) such as dressing or combing one’s hair, although actual motor abil-ities are intact. Clients cannot imitate the task when others demonstrate it for them. In the severe stage, clients may experience a gait disturbance that makes unassisted ambu-lation unsafe, if not impossible.

Some clients with dementia show uninhibited behavior, including making inappropriate jokes, neglecting personal hygiene, showing undue familiarity with strangers, or dis-regarding social conventions for acceptable behavior. This can include the use of profanity or making disparaging remarks about others when clients have never displayed these behaviors before.

Mood and Affect

Initially, clients with dementia experience anxiety and fear over the beginning losses of memory and cognitive func-tions. Nevertheless, they may not express these feelings to anyone. Mood becomes more labile over time and may shift rapidly and drastically for no apparent reason. Emo-tional outbursts are common and usually pass quickly. Cli-ents may display anger and hostility, sometimes toward other people. They begin to demonstrate catastrophic emotional reactions in response to environmental changes that clients may not perceive or understand accurately or when they cannot respond adaptively. These catastrophic reactions may include verbal or physical aggression, wan-dering at night, agitation, or other behaviors that seem to indicate a loss of personal control.

Clients may display a pattern of withdrawal from the world they no longer understand. They are lethargic, look apathetic, and pay little attention to the environment or the people in it. They appear to lose all emotional affect and seem dazed and listless.

Thought Process and Content

Initially, the ability to think abstractly is impaired, resulting in loss of the ability to plan, sequence, monitor, initiate, or stop complex behavior (APA, 2000). The client loses the ability to solve problems or to take action in new situations because he or she cannot think about what to do. The abil-ity to generalize knowledge from one situation to another is lost because the client cannot recognize similarities or differences in situations. These problems with cognition make it impossible for the employed client to continue working. The client’s ability to perform tasks such as plan-ning activities, budgeting, or planning meals is lost.

As the dementia progresses, delusions of persecution are common. The client may accuse others of stealing objects he or she has lost or may believe he or she is being cheated or pursued.

Sensorium and Intellectual Processes

Clients lose intellectual function, which eventually involves the complete loss of their abilities. Memory defi-cits are the initial and essential feature of dementia. Dementia first affects recent and immediate memory and then eventually impairs the ability to recognize close fam-ily members and even oneself. In mild and moderate dementia, clients may make up answers to fill in memory gaps (confabulation). Agnosia is another hallmark of dementia. Clients lose visual spatial relations, which is often evidenced by deterioration of the ability to write or draw simple objects.

Attention span and ability to concentrate are increas-ingly impaired until clients lose the ability to do either. Clients are chronically confused about the environment, other people, and eventually themselves. Initially, they are disoriented to time in mild dementia, time and place in moderate dementia, and finally to self in the severe stage.

Hallucinations are a frequent problem. Visual halluci-nations are most common and generally unpleasant. Cli-ents are likely to believe the hallucination is reality.

Judgment and Insight

Clients with dementia have poor judgment in light of the cognitive impairment. They underestimate risks and unre-alistically appraise their abilities, which result in a high risk for injury. Clients cannot evaluate situations for risks or danger. For example, they may wander outside in the winter wearing only thin nightclothes and not consider this to be a risk.

Insight is limited. Initially, the client may be aware of problems with memory and cognition and may worry that he or she is “losing my mind.” Quite quickly, these con-cerns about the ability to function diminish, and clients have little or no awareness of the more serious deficits that have developed. In this context, clients may accuse others of stealing possessions that the clients themselves have actually lost or forgotten.

Self-Concept

Initially, clients may be angry or frustrated with them-selves for losing objects or forgetting important things. Some clients express sadness at their bodies for getting old and at the loss of functioning. Soon, though, clients lose that awareness of self, which gradually deteriorates until they can look in a mirror and fail to recognize their own reflections.

Roles and Relationships

Dementia profoundly affects the client’s roles and relation-ships. If the client is still employed, work performance suf-fers, even in the mild stage of dementia, to the point that work is no longer possible given the memory and cogni-tive deficits. Roles as spouse, partner, or parent deteriorate as clients lose the ability to perform even routine tasks or recognize familiar people. Eventually, clients cannot meet even the most basic needs.

Inability to participate in meaningful conversation or social events severely limits relationships. Clients quickly become confined to the house or apartment because they are unable to venture outside unassisted. Close family members often begin to assume caregiver roles; this can change previously established relationships. Grown chil-dren of clients with dementia experience role reversal; that is, they care for parents who once cared for them. Spouses or partners may feel as if they have lost the previous rela-tionship and now are in the role of custodian.

Physiologic and Self-Care Considerations

Clients with dementia often experience disturbed sleep– wake cycles; they nap during the day and wander at night. Some clients ignore internal cues such as hunger or thirst; others have little difficulty with eating and drinking until dementia is severe. Clients may experience bladder and even bowel incontinence or have difficulty cleaning them-selves after elimination. They frequently neglect bathing and grooming. Eventually, clients are likely to require complete care from someone else to meet these basic physiologic needs. 

Data Analysis

Many nursing diagnoses can be appropriate because the effects of dementia on clients are profound; the disease touches virtually every part of their lives. Commonly used nursing diagnoses include the following:

·    Risk for Injury

·    Disturbed Sleep Pattern

·    Risk for Deficient Fluid Volume

·    Risk for Imbalanced Nutrition: Less Than Body Requirements

·    Chronic Confusion

·    Impaired Environmental Interpretation Syndrome

·    Impaired Memory

·    Impaired Social Interaction

·    Impaired Verbal Communication

·    Ineffective Role Performance

In addition, the nursing diagnoses of Disturbed Thought Processes and Disturbed Sensory Perception would be appropriate for a client with psychotic symptoms. Multi-ple nursing diagnoses related to physiologic status also may be indicated based on the nurse’s assessment, such as alterations in nutrition, hydration, elimination, physical mobility, and activity tolerance.

Outcome Identification

Treatment outcomes for clients with progressive demen-tia do not involve regaining or maintaining abilities to function. In fact, the nurse must reassess overall health status and revise treatment outcomes periodically as the client’s condition changes. Outcomes and nursing care that focus on the client’s medical condition or deficits are common. Current literature proposes a focus on psychosocial care that maximizes the client’s strengths and abilities for as long as possible. Psychosocial care involves maintaining the client’s independence as long as possible, validating the client’s feelings, keeping the client involved in the environment, and dealing with behavioral disruptions respectfully (McCabe, 2008; Ouldred & Bryant, 2008; Yuhas et al., 2006). Treatment outcomes for a client with dementia may include the following:

·    The client will be free of injury.

·    The client will maintain an adequate balance of activity and rest, nutrition, hydration, and elimination.

·    The client will function as independently as possible given his or her limitations.

·    The client will feel respected and supported.

·    The client will remain involved in his or her surroundings.

·    The client will interact with others in the environment.

Intervention

Psychosocial models for care of clients with dementia are based on the approach that each client is a unique person and remains so, even as the disease’s progression blocks the client’s ability to demonstrate those unique character-istics. Interventions are rooted in the belief that clients with dementia have personal strengths. They focus on demonstrating caring, keeping clients involved by relating to the environment and other people, and validating feel-ings and dignity of clients by being responsive to them, offering choices, and reframing (offering alternative points of view to explain events). This is in contrast to medical models of care that focus on progressive loss of function and identity (McCabe, 2008).

Nurses can use the following interventions in any set-ting for clients with dementia. Education for family members caring for clients at home and for professional caregivers in residential or skilled facilities is an essen-tial component of providing safe and supportive care. The discussion provides examples that apply to various settings.

Promoting the Client’s Safety

Safety considerations involve protecting against injury, meeting physiologic needs, and managing risks posed by the environment, including internal stimuli such as delu-sions and hallucinations. Clients cannot accurately appraise the environment and their abilities; therefore, they do not exercise normal caution in daily life. For example, the client living at home may forget food cook-ing on the stove; the client living in a residential care setting may leave for a walk in cold weather without a coat and gloves. Assistance or supervision that is as unobtru-sive as possible protects clients from injury while preserv-ing their dignity.

A family member might say,

“I’ll sit in the kitchen and talk to you while you make lunch” (suggesting collaboration) rather than “You can’t cook by yourself because you might set the house on fire.” 

In this way, the nurse or caregiver supports the client’s desire and ability to engage in certain tasks while provid-ing protection from injury.

Clients with dementia may believe that their physical safety is jeopardized; they may feel threatened or suspi-cious and paranoid. These feelings can lead to agitated or erratic behavior that compromises safety. Avoiding direct confrontation of the client’s fears is important. Clients with dementia may struggle with fears and suspicion through-out their illness. Triggers of suspicion include strangers, changes in the daily routine, or impaired memory. The nurse must discover and address these environmental trig-gers rather than confront the paranoid ideas.

For example, a client reports that his belongings have been stolen. The nurse might say,

“Let’s go look in your room and see what’s there.”

and help the client to locate the misplaced or hidden items (suggesting collaboration). If the client is in a room with other people and says, “They’re here to take me away!” the nurse might say,

“Those people are here visiting with someone else. Let’s go for a walk and let them visit.” (presenting reality/distraction)

The nurse then can take the client to a quieter and less stimulating place, which moves the client away from the environmental trigger.

Promoting Adequate Sleep and Proper Nutrition, Hygiene, and Activity

Clients require assistance to meet basic physiologic needs. The nurse monitors food and fluid intake to ensure ade-quacy. Clients may eat poorly because of limited appetite or distraction at mealtimes. The nurse addresses this problem by providing foods clients like, sitting with cli-ents at meals to provide cues to continue eating, having nutritious snacks available whenever clients are hungry, and minimizing noise and undue distraction at mealtimes. Clients who have difficulty manipulating utensils may be unable to cut meat or other foods into bite-sized pieces. The food should be cut up when it is prepared, not in front of clients, to deflect attention from their inability to do so. Food that can be eaten without utensils, or finger foods such as sandwiches and fresh fruit, may be best. In contrast, clients may eat too much, even ingesting inedi-ble items. Providing low-calorie snacks such as carrot and celery sticks can satisfy the desire to chew and eat without unnecessary weight gain. Enteral nutrition often becomes necessary when dementia is most severe, although not all families choose to use tube feedings.

Adequate intake of fluids and food is also necessary for proper elimination. Clients may fail to respond to cues indicating constipation, so the nurse or caregiver monitors the client’s bowel elimination patterns and intervenes with increased fluids and fiber or prompts as needed. Urinary elimination can become a problem if clients do not respond to the urge to void or are incontinent. Reminders to uri-nate may be helpful when clients are still continent but not initiating use of the bathroom. Sanitary pads can address dribbling or stress incontinence; adult diapers, rather than indwelling catheters, are indicated for incontinence. The nurse checks disposable pads and diapers frequently and changes soiled items promptly to avoid infection, skin irri-tation, and unpleasant odors. It is also important to pro-vide good hygiene to minimize these risks.

Balance between rest and activity is an essential compo-nent of the daily routine. Mild physical activity such as walking promotes physical health but is not a cognitive challenge. Daily physical activity also helps clients to sleep at night. The nurse provides rest periods so clients can conserve and regain energy, but extensive daytime napping may interfere with nighttime sleep. The nurse encourages clients to engage in physical activity because they may not initiate such activities independently; many clients tend to become sedentary as cognitive abilities diminish. Clients often are quite willing to participate in physical activities but cannot initiate, plan, or carry out those activities with-out assistance.

Structuring the Environment and Routine

A structured environment and established routines can reassure clients with dementia. Familiar surroundings and routines help to eliminate some confusion and frustration from memory loss. Providing routines and structure, how-ever, does not mean forcing clients to conform to the struc-ture of the setting or routines that other people determine. Rather than imposing new structure, the nurse encourages clients to follow their usual routines and habits of bathing and dressing (Yuhas et al., 2006). For example, it is impor-tant to know whether a client prefers a tub bath or shower and washes at night or in the morning and to include those preferences in the client’s care. Research has shown that attempting to change the dressing behavior of clients may result in physical aggression as clients make ineffective attempts to resist unwanted changes. Monitoring response to daily routines and making needed adjustments are important aspects of care.

The nurse needs to monitor and manage the client’s tol-erance of stimulation. Generally, clients can tolerate less stimulation when they are fatigued, hungry, or stressed. Also, with the progression of dementia, tolerance for envi-ronmental stimuli decreases. As this tolerance diminishes, clients need a quieter environment with fewer people and less noise or distraction.

Providing Emotional Support

The therapeutic relationship between client and nurse involves “empathic caring,” which includes being kind, respectful, calm, and reassuring and paying attention to the client. Nurses use these same qualities with many dif-ferent clients in various settings. In most situations, clients give positive feedback to the nurse or caregiver, but clients with dementia often seem to ignore the nurse’s efforts and may even respond with negative behavior such as anger or suspicion. This makes it more difficult for the nurse or caregiver to sustain caring behavior. Nevertheless, nurses and caregivers must maintain all the qualities of the thera-peutic relationship even when clients do not seem to respond.

Because of their disorientation and memory loss, clients with dementia often become anxious and require much patience and reassurance. The nurse can convey reassur-ance by approaching the client in a calm, supportive man-ner, as if nurse and client are a team—a “we can do it together” approach. The nurse reassures the client that he or she knows what is happening and can take care of things when the client is confused and cannot do so. For exam-ple, if the client is confused about getting dressed, the nurse might say,

“I’ll be glad to help you with that shirt. I’ll hold it for you while you put your arms in the sleeves.” (offering self/suggesting collaboration) 

Supportive touch is effective with many clients. Touch can provide reassurance and convey caring when words may not be understood. Holding the hand of the client who is tearful and sad and tucking the client into bed at night are examples of ways to use supportive touch. As with any use of touch, the nurse must evaluate each cli-ent’s response. Clients who respond positively will smile or move closer toward the nurse. Those who are threat-ened by physical touch will look frightened or pull away from the nurse, especially if the touch is sudden or unex-pected or if the client misperceives the nurse’s intent.

Promoting Interaction and Involvement

In a psychosocial model of dementia care, the nurse or caregiver plans activities that reinforce the client’s identity and keep him or her engaged and involved in the business of living (Yuhas et al., 2006). The nurse or caregiver tailors these activities to the client’s interests and abilities: They should not be routine group activities that “everyone is supposed to do.” For example, a client with an interest in history may enjoy documentary programs on television; a client who likes music may enjoy singing. Clients often need the involvement of another person to sustain atten-tion in the activity and to enjoy it more fully. Those who have long periods without anything to engage their inter-est are more likely to become restless and agitated. Clients engaged in activities are more likely to stay calm. A wide variety of activities have proven beneficial for clients with dementia. Music, dancing, pet- or animal-assisted therapy, aromatherapy, and multisensory stimulation are examples of activities that can be explored to maximize the client’s involvement with the environment and enhance the qual-ity of his or her life (Milev, 2008; Ouldred & Bryant, 2008; Raglio et al., 2008).

Reminiscence therapy (thinking about or relating per-sonally significant past experiences) is an effective inter-vention for clients with dementia. Rather than lamenting that the client is “living in the past,” this therapy encour-ages family and caregivers also to reminisce with the cli-ent. Reminiscing uses the client’s remote memory, which is not affected as severely or quickly as recent or immediate memory (McCabe, 2008). Photo albums may be useful in stimulating remote memory, and they provide a focus on the client’s past. Sometimes clients like to reminisce about local or national events and talk about their roles or what they were doing at the time. In addition to keeping clients involved in the business of living, reminiscence also can build self-esteem as clients discuss accomplishments. Engaging in active listening, asking questions, and provid-ing cues to continue promote successful use of this tech-nique. Reminiscence therapy can also be effective with small groups of clients as they collectively remember their early life activities (Wang, 2007).

Clients have increasing problems interacting with oth-ers as dementia progresses. Initially, clients retain verbal language skills, but other people may find them difficult to understand as words are lost or content becomes vague. The nurse must listen carefully to the client and try to determine the meaning behind what is being said. The nurse might say,

“Are you trying to say you want to use the bath-room?” or “Did I get that right, you are hun-gry?” (seeking clarification) 

It is also important not to interrupt clients or to finish their thoughts. If a client becomes frustrated when the nurse cannot understand his or her meaning, the nurse might say,

“Can you show me what you mean or where you want to go?” (assisting to take action) 

When verbal language becomes less coherent, the nurse should remain alert to the client’s nonverbal behavior.

When nurses or caregivers consistently work with a par-ticular client, they develop the ability to determine the cli-ent’s meaning through nonverbal behavior. For example, if the client becomes restless, it may indicate that he or she is hungry if it is close to mealtime or tired if it is late in the evening. Sometimes it is impossible to determine exactly what the client is trying to convey, but the nurse can still be responsive. For example, a client is pacing and looks upset but cannot indicate what is bothering her. The nurse says,

“You look worried. I don’t know what’s wrong, but let’s go for a walk.” (making an observation/ offering self) 

Interacting with clients with dementia often means deal-ing with thoughts and feelings that are not based in reality but arise from the clients’ suspicion or chronic confusion. Rather than attempting to explain reality or allay suspicion or anger, it is often helpful to use the techniques of distrac-tion, time away, or going along to reassure the client.

Distraction involves shifting the client’s attention and energy to a more neutral topic. For example, the client may display a catastrophic reaction to the current situa-tion, such as jumping up from dinner and saying, “My food tastes like poison!” The nurse might intervene with distraction by saying,

“Can you come to the kitchen with me and find something you’d like to eat?” or “You can leave that food. Can you come and help me find a good  program  on  television?”  (redirection/distraction)

Clients usually calm down when the nurse directs their attention away from the triggering situation.

Time away involves leaving clients for a short period and then returning to them to re-engage in interaction. For example, the client may get angry and yell at the nurse for no discernible reason. The nurse can leave the client for about 5 or 10 minutes and then return without referring to the previous outburst. The client may have little or no memory of the incident and may be pleased to see the nurse on his or her return.

Going along means providing emotional reassurance to clients without correcting their misperception or delusion. The nurse does not engage in delusional ideas or reinforce them, but he or she does not deny or confront their exis-tence. For example, a client is fretful, repeatedly saying, “I’m so worried about the children. I hope they’re okay,” and speaking as though his adult children were small and needed protection. The nurse could reassure the client by saying,

“There’s no need to worry; the children are just fine” (going along),

which is likely to calm the client. The nurse has responded effectively to the client’s worry without addressing the reality of the client’s concern. Going along is a specific intervention for clients with dementia and should not be used with those experiencing delusions whose conditions are expected to improve.

The nurse can use reframing techniques to offer clients different points of view or explanations for situations or events. Because of their perceptual difficulties and confu-sion, clients frequently interpret environmental stimuli as threatening. Loud noises often frighten and agitate them. For example, one client may interpret another’s yelling as a direct personal threat. The nurse can provide an alterna-tive explanation such as

“That lady has many family problems, and she yells sometimes because she’s frustrated.” (reframing)

Alternative explanations often reassure clients with demen-tia and help them become less frightened and agitated.

Evaluation

Treatment outcomes change constantly as the disease pro-gresses. For example, in the early stage of dementia, main-taining independence may mean that the client dresses with minimal assistance. Later, the same client may keep some independence by selecting what foods to eat. In the late stage, the client may maintain independence by wear-ing his or her own clothing rather than an institutional nightgown or pajamas.

The nurse must assess clients for changes as they occur and revise outcomes and interventions as needed. When a client is cared for at home, this includes providing ongo-ing education to family members and caregivers while supporting them as the client’s condition worsens. See the sections that follow on the role of the caregiver and com-munity-based care.