The latest reports from the Alzheimer's Disease Association offer startling statistics about the incidence and prevalence of Alzheimer's disease, the major dementia. The statistics are particularly devastating for the fastest growing segment of our aging population, those who are aged 85 and older. With interest focused on Alzheimer's disease, nurses and caregivers must be particularly vigilant in differentiating the dementias from one another, particularly if the dementia is treatable.
Nurses need to be at the forefront in the management of the dementias. Caregivers often ask nurses for management information. A great deal of management information is achieved through trial and error techniques until the nurse discovers the best way to manage a particular patient.
Shaid provides information for patient management with insight gained from a Holocaust victim. Shaid demonstrates the importance of knowing the patient's history. She shows how early traumatic events can surface later to cause distress that is not easily understood by nurses and caregivers. Shaid's case study serves as an example for other patients who may be experiencing poorly understood traumas.
Nurses spend the most time with patients, particularly in nursing homes. Thus, nurses are more likely to pick up clues that signify other treatable dementias in patients, even if a diagnosis of Alzheimer's disease has already been made. One of these treatable dementias is Binswanger's disease, dayman offers insight into Binswanger's dementia and the importance of early and accurate diagnosis. She gives us enough information to whet our appetites and make us realize how much more information we need.
Each of these clinicians offers personal experiences to share with other nurses in practice. Perhaps their experiences will facilitate the work of at least one more nurse and assist one more patient.
Barbara K. Haight, RNC, DrPH
Traumatic Early Life Events
As average life expectancy increases, so, too, will the prevalence of chronic illness. Of particular concern is dementia, a health problem with many questions and few answers. A variety of etiologies are encompassed by the syndrome "dementia" and include senile dementia of the Alzheimer's type (SDAT), multi-infarct dementia (MID), Binswanger's disease, Pick's disease, Huntington's chorea, normal pressure hydrocephalus, Creutzfeldt-Jakob disease, and Parkinson's disease (Abrams, 1990; Butler, 1983).
Common Changes Seen With SDAT
As with other forms of dementia, SDAT, by its nature, causes losses in cognitive function (Table 1).
Research on long-term memory storage with is of increasing because of for theraintervention. In a by Morris, and Britton (1983), cued recall of past assisted in retrieving from longmemory; the could be through manipuof external conditions. The therapy proved beneficial for who gained in following the intervention.
Reality orientation, frequently described as a useful form of therapy with cognitively impaired older adults, is increasingly being replaced by reminiscence, group psychotherapy, and validation. Reminiscence, like cued recall, assists in retrieval from long-term memory. Youssef (1990) used reminiscence with dementia patients to aid in adjustment and to relieve depression. Kovach (1990) describes the benefits of reminiscence therapy based on available research, but also notes the limitations in many of these studies and the need for additional evaluation of psychotherapy.
In other research, Akerlund and Norberg (1986) compared group psychotherapy with reality orientation. Findings from their pilot study suggest that psychotherapy improves communication abilities in some patients. Validation therapy has also been reported as beneficial with the demented patient and underlies the work of Akerlund and Norberg (Akerlund, 1986; Feil, 1984). In both validation and reminiscence therapy, clinicians rely on longterm memory as they help the person focus on happy events from the past. It is believed that such memories calm behavior and improve cognitive Function.
Although one avenue of current research in the management of dementia focuses on remembering the past and using those memories to improve psychological well-being and cognitive abilities, the affect of remembering a traumatic early Life event on the patient is unknown. Almost everyone can recall an unpleasant past event.
The circumstances may have been devastating, such as surviving the Holocaust, participating in a war, or enduring a natural disaster. Coping patterns vary, and there are many ways of handling crises. For some, "time heals all wounds" as memories are suppressed and normal life resumes. When cognitive losses result in impaired shortterm memory, communication, and coping skills, could those losses enable retrieval of suppressed memories and stored information? What can be expected when these long suppressed memories resurface?
The following case example describes a woman who was the unfortunate victim of societal abuse as a child and young adult. Today, at age 86, Betty remains troubled by memories of mistreatment that overshadow any thoughts of more tranquil times.
The traumatic experiences in Betty's past, coupled with her disorientation and treatment by staff and other residents, appears to trigger the resurfacing of troubling, even frightening, memories. A thorough review of her history and evaluation of present behavior seems warranted if her anxiety and stress are to be managed more effectively.
Betty's outbursts focus on fears and anxieties associated with her environment. Periods of detachment could occur when she is remembering, imagining, or hallucinating about the past. Persons with SDAT reportedly experience perceptual deficits relating to illusions, delusions, and hallucinations, which may, in turn, contribute to paranoia and aggression (Beck, 1988). As seen with Betty, she appears to experience perceptual difficulties through illusions, suspiciousness of her environment (paranoia), and aggression (vocal outbursts). Furthermore, these perceptual difficulties are reinforced by interactions with staff and other residents.
To respond to increased agitation by removing Betty to a quiet room may intensify memories and fears of being locked in the cellar. Verbal and physical reprisals, as she has experienced in the nursing home, may serve as reminders of abusive situations known during her youth in Austria. Her comment about the danger to the old woman without a lock on her door may be an expression of fear from the inability to lock her own bedroom door. Despite intentions to calm or quiet her, the consequence of reprimands by the staff apparently heighten a perception of danger. Impaired short-term memory makes it impossible for Betty to remember that many years have passed and that she is now safe.
This case illustrates many issues that will be faced as the elderly population, many of whom will develop some form of dementia, increases. The traumatic events of the 20th century, including the Holocaust, Hiroshima and Nagasaki, wars, natural disasters, and painful national and international events and tragedies, as well as personal trauma (for example, death of loved ones, job failure, health problems, loss of home and security), will live on in the memories of the aging survivors. With dementia and the failing of short-term memory, such traumatic events can resurface, requiring intervention which is, as yet, poorly understood.
Despite a lack of knowledge concerning this phenomenon, it is, nevertheless, troubling when residents like Betty are not cared for with greater compassion and understanding. Residents with behavioral problems are often difficult and unpleasant, but inappropriate actions by staff exacerbate the situation.
Rather than scold or isolate Betty, staff tried to provide comfort, attention, and a sense of security. Making sense of her behavior helped staff to understand Betty.
With implementation of the Omnibus Budget reconciliation Act of 1987, and the requirement for each resident to have completed a Minimum Data Set (Minimum Data Set, 1989), basic demographic, physical, social, and behavioral data will be collected. A section of the Minimum Data Set concerned with psychosocial well-being addresses three basic items: sense of initiative/ involvement, unsettled relationships, and past roles. Exploration of these areas allows for the identification of significant events during the resident's lifetime. For people like Betty, such knowledge would considerably enhance the staff's understanding of behavior. The resident assessment protocols accompanying the Minimum Data Set should guide a plan of care focused on better communication and altered patterns of coping.
Appropriate Interventions for a Patient With SDAT and Early Traumatic Memories
Once Betty's needs are identified, the task is to find appropriate interventions. Unfortunately, knowledge is limited concerning the direction to be taken in persons with dementia elicited by memories of an early traumatic event. Validation and reminiscence may be inappropriate therapies because of anxiety, as demonstrated by Betty's statement: 'To call it back to someone who has lived through a catastrophe is very bad." Reminiscence may intensify recollections, and validation could aggravate symptoms and cause further behavioral manifestations by confirming the feelings associated with Betty's suspicions and fears. Reality orientation was not helpful with Betty; it appeared to worsen her confusion and agitation.
The literature does not offer a great deal for this particular phenomenon.
Some potential guidelines can be extrapolated from The 36-Hour Day by Mace and Rabins (1981). Elsewhere, Hall and Buckwalter, using a case study approach, demonstrate the importance of understanding a person's history and pattern of disease (StrandeU, 1989). Hall and Buckwalter outline interventions focused on persons with SDAT who are experiencing symptoms of suspiciousness, delusions, illusions, or hallucinations (HaU, in press; 1991). Under these circumstances, the caregiver or clinician should remain calm, ignore the disturbing behavior as much as possible, and respond with kindness and comfort. Other appropriate interventions are listed in Table 2.
Current therapeutic regimens for persons with SDAT do not address the problem of recurrent memories from an early traumatic experience. A largely unrecognized entity at this time, it is likely to increase with the rising prevalence of dementia. Providers of care to an older population need to be prepared to help people to cope with memories of past events that have long been suppressed.
This becomes a greater challenge when cognitive impairment affects memory, coping skills, and communication. The only currently available interventions are those derived from a preliminary literature search incorporating strategies from reality orientation, reminiscence therapy, group psychotherapy, and validation therapy. A great challenge for the future is to develop the skills to manage this problem more effectively. The case presented here, however, suggests that legitimate approaches include proper identification of contributing events in the resident's early life with interventions focused on management of the behaviors elicited by the resident.
Betty is widowed, 86 years old, and has resided in a nursing home for 9 months following discharge from a.nearby hospital. Prior to hospitalization, Betty had lived in her own apartment with a companion. Her posthospital physical, mental, and emotional needs, however, required extensive attention and the need for additional care.
On admission to the nursing home, this 5-ft, 85-lb, frail Jewish woman did not know the date or present location. She was confused, easily agitated, and occasionally incontinent of bladder and bowel. She was able to feed herself but required assistance with bathing and dressing. Her âpraxic gait and severe arthritis slowed her ambulation and she required a walker. The recreational therapist reports that Betty enjoys musical entertainment, social parties/ Bingo, pet therapy, and exercise.
Betty's past medical history is significant for hypertension, SDAT, aortic stenosis, anemia, old hip fracture, right cataract, dorsal kyphosis, and multiple seborrheic kératoses, A diagnosis of MID also appears in the medical record. Her hearing is poor; however, she does not use a hearing aid. She wears corrective lenses and full upper and lower dentures. Her rehabilitation potential and prognosis are listed as fair. Goals for Betty include increased socialization and improved gait.
Betty's 9-month history at the nursing home has been characterized by frequent episodes of agitation and verbal outbursts. The nursing progress notes document frequent "screaming episodes," noisiness, and agitation. No physical restraints are used with Betty; however, Haldol (haloperidol) is given and staff record that the screaming episodes are "improving with medication." The staff report confining the resident to her room when agitation increases, but "fears when left alone" have also been documented. Betty is harassed by other residents when she screams in the dining room, and residents have been reported to hit her, causing her to fall over her walker.
Staff and residents either tell Betty to "shut up" or ignore her outbursts entirely. During shouting episodes, Betty has a "faraway" look on her face and appears unaware of her environment.
Although she is fluent in English, Betty frequently shouts in German and Yiddish. This infuriates staff and other residents as they are then unable to understand her. Betty yells "nein," "ahhh," "lucifer," and a phrase in German that, when translated to English, means, "They're trying to kill me." Betty tells staff that she yells to get attention and will continue to do so until someone comes to help. Interested staff have tried techniques to control anxiety, including one-to-one conversation, physical touch, group activities, increased socialization, and distraction through the use of picture magazines. Betty is completely calm when receiving any form of attention. Her anxiety appears controlled when she is involved in a purposeful activity, such as walking.
Past history includes birth in Vienna, Austria, in 1 904. Betty describes this as a time when the Jewish people of Eastern Europe were persecuted for their religious beliefs. She speaks of this time in the present tense and states that Austria is "dangerous" because the people are "hateful of Jews." She states that they have "guns," "come in the night to shoot people," and she "feels bad" with "all the terrible things I see. I see this old woman, there is no lock on the door and it is dangerous."
On the other hand, she also makes statements that suggest she is oriented, for example, "When I talk about it now it seems so strange to me. I cannot even talk about it." She often gets an anxious look on her face and asks staff members, "How can you look so good in such bad times?" When asked when she came from Austria, she says 6 weeks ago, despite the fact that she arrived in the US more than 60 years ago. She states, 'They were very bad times," and 'To call it back to someone who has lived through a catastrophe is very bad." She is aware of and states that they ". . . killed 6 million people in the Holocaust," but she has difficulty distinguishing when the Holocaust occurred. For the most part, staff are unaware of Betty's past, except for a social worker who knew Betty had been born in Austria, had been locked in a cellar, and had emigrated to the US as a young adult.
Abrams, W., Berkow, R. (Eds.). The March manual of geriatrics.
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Akerlund, B-, Norberg, A. Group psychotherapy with demented patients. Geriatr Nurs 1986; 7:83-84.
Beck, C., Heacock, P. Nursing interventions for patients with Alzheimer's disease. Nurs Clin North Am 1988; 23:95-124.
Butler, R-, Lewis, M. Aging and mental health. New York: CV Mosby Co, 1983.
Cohen, D., Kennedy, G-, Eivdorfer, C. Phases of change in the patient with Alzheimer's dementia: A conceptual dimension for defining health care management. / Am Geriatr Soc 1984; 32:11-15.
Feil, N. Communicating with the confused elderly patient. Geriatrics 1984; 39:131-132.
Hall, G. Alterations in thought process: Progressive degeneration of the cerebral cortex. In M. Maas, K.
Buckwalter (Eds.), Nursing diagnosis and interventions for the elderly. Menlo Park, CA: Addison-Wesley, in press.
Hall, G.R. Care of the patient with Alzheimer's disease living at home. Nurs Clin North Am 1988; 23:31-36.
Hall, G.R., Buckwalter, K.C. Whole disease care planning: Fitting the program to the client with Alzheimer's disease, journal of Geronlological Nursing 1991; 17(2):38-41.
Kovach, C.R. Promise and problems in reminiscence research. Journal of Gerontolagica! Nursing 1990; 16(4): 10-1 4.
Mace, N., Rabins, P. The 36-hour day. New York: Warner Books, 1981.
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Elizabeth Chapman Shaid, RN, AISN, CRNP, Manager
The Whitman Group Huntingdon Valle/,
Binswanger's Disease ___
An estimated quarter of a million Americans suffer from vascular dementia (multi-infarct dementia). This is second only to SDAT. Magnetic resonance imaging in the elderly has demonstrated a common occurrence of deep white matter lesions in the aging brain (Binswanger's dementia). This disease is important to clinicians in the differential diagnosis of dementia and warrants teaching by the practitioner.
In 1894, Bins wanger identified a slowly progressive dementia in the white matter of the brain. However, the disease could not be readily diagnosed until autopsy. With the onset of magnetic resonance imaging, the disease can now be diagnosed with some accuracy. The need to be able to differentiate Binswanger's dementia from the typical multiinfarct type is important because of the risk factors associated with the dementia of the Binswanger's type (SDBT). Hypertension, diabetes, cardiovascular disease, and recurrent hypotension are frequent risk factors (Roman, 1987).
Unlike SDAT, the progression of SDBT could be slowed with education of the client (Roman, 1987). Because risk factors of SDBT have been suggested, teaching the patient or family about the importance of controlling diabetes, hypertension, hypotension, and other cardiovascular diseases is primary in gerontological nursing (Roman, 1987).
The observable symptoms of SDBT can resemble those of SDAT (eg, forgetfulness, confusion, incontinence). However, research has shown that clients with SDBT usually present early with gait disorders, frequent falls, and urinary incontinence (Roman, 1987). This is quite different from SDAT in that gait disorders, falls, and urinary incontinence are much later signs of the disease. Not unlike SDAT, changes in mood and behavior are prevalent symptoms in SDBT. In contrast to multi-infarct dementia, the symptoms of SDBT fluctuate frequently, reaching a plateau or even improving for months or years. Rapid deterioration has also been shown to occur in clients who have just had surgical procedures, cardiac arrythmias, recurrent hypotension, or syncope. Definitive diagnosis can only be accomplished with magnetic resonance imaging.
Caution must be taken regarding over-diagnosis of this type of dementia. Lesions suggestive of SDBT appear on the magnetic resonance image as a brightly illuminated halo. The differential diagnosis of SDBT involves other causes of damaged white matter (eg, edema, métastases, stroke). It is most important to refer patients to imaging centers that employ radiologists experienced in the diagnosis of SDBT. Early and accurate diagnosis of SDBT is crucial to the client because fairly preventive and therapeutic changes can halt or slow the progression of this vascular dementia. It behooves us as professionals to be knowledgeable about SDBT and assist clients in adequate teaching about reducing high blood pressure, keeping diabetes under control, and monitoring cardiac status frequently.
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Andrea Cfcrymon, AtSN,
Vice President, Heritage
Kimball Medical Center
Lakewood, New Jersey
Common Changes Seen With SDAT
Appropriate Interventions for a Patient With SDAT and Early Traumatic Memories