Care of the Older Adult

Dementia, Depression, Delirium

Dementia, Depression, Delirium

Learning Outcomes
Differentiate among dementia, depression, and
delirium…

Identify the stages and clinical features of dementia…

Recognize and address the common causes of

delirium…

Discuss the theoretical foundations of nursing care for

persons with dementia…

Apply basic principles to provide safe and effective

care for persons with dementia.
Dementia
A general term that refers to progressive,
degenerative brain dysfunction, including
deterioration in memory, concentration, language
skills, visuospatial skills, and reasoning, that
interferes with a person’s daily functioning.
Although more common in older adults than in
younger persons, dementia is not considered a
normal part of aging…

Risk Factors: Age, Family History, Genetics, Head

Trauma, Vascular diseases, Infections
Most Common Types of Dementia
in Older Adults

Alzheimer’s disease (most common)

Vascular dementia (considered the second most-

common form of dementia, after Alzheimer’s)

Mixed Alzheimer’s/vascular dementia

Parkinson’s dementia

Lewy body dementia

Frontotemporal lobe dementia

Most Common Types of Dementia
in Older Adults (Alzheimer’s disease)
Characteristics:

• Most common form of dementia.

• Progressive decline in memory, reasoning, and other cognitive functions.

• Early symptoms: Difficulty remembering recent events or names.

• Later stages: Language impairment, disorientation, mood changes, and impaired daily
functioning.

• Neuropathology: Accumulation of beta-amyloid plaques and tau tangles in the brain.

Risk Factors: Age, genetics (e.g., APOE-e4 allele), family history.

Progression: Gradual and steady.

Most Common Types of Dementia
in Older Adults (Vascular dementia)
Characteristics:

• Second most common form of dementia.

• Results from impaired blood flow to the brain (e.g., strokes or small vessel disease).

• Symptoms depend on the affected brain regions but typically include problems
with planning, reasoning, judgment, and memory.

• May present abruptly after a stroke or progress in a stepwise manner with

additional vascular events.

Risk Factors: Hypertension, diabetes, smoking, high cholesterol, cardiovascular disease.

Progression: Variable; stepwise or gradual, depending on ongoing vascular damage.

Most Common Types of Dementia
in Older Adults (Alzheimer’s+vascular dementia)
Characteristics:

• A combination of Alzheimer’s pathology (plaques/tangles) and vascular

damage.

• Symptoms overlap with both conditions, including memory loss,

confusion, and executive dysfunction.

• Often more severe cognitive decline than seen in either condition alone.

Risk Factors: Combination of Alzheimer’s and vascular risk factors.

Progression: More rapid compared to Alzheimer’s or vascular dementia alone.

Most Common Types of Dementia
in Older Adults (Parkinson’s dementia)
Characteristics:

• Occurs in individuals with Parkinson’s disease, usually years after motor

symptoms appear.

• Symptoms include slowed thinking, impaired memory, executive

dysfunction, hallucinations, and difficulty with complex tasks.

• Neuropathology: Presence of Lewy bodies (abnormal protein deposits) in the

brain.

Risk Factors: Parkinson’s disease, age, severity of motor symptoms.

Progression: Gradual, often following worsening motor symptoms.

Most Common Types of Dementia
in Older Adults (Lewy body dementia)
Characteristics:

• Shares features with both Parkinson’s disease and Alzheimer’s.

• Early symptoms include fluctuating attention/alertness, visual hallucinations,

REM sleep disturbances, and parkinsonism (rigidity, tremor, bradykinesia).

• Sensitivity to antipsychotic medications (can worsen symptoms).

• Neuropathology: Widespread Lewy body deposition.

Risk Factors: Age, male gender, family history.

Progression: Progressive but often fluctuates in severity day-to-day.

Most Common Types of Dementia
in Older Adults (Frontotemporal lobe dementia)
Characteristics:

• Affects the frontal and/or temporal lobes of the brain, leading to distinct behavioral or language
changes.

Subtypes:

1. Behavioral variant: Personality changes, disinhibition, apathy, loss of empathy.

2. Primary progressive aphasia: Difficulty with speech and language.

• Memory often preserved in early stages.

• Neuropathology: Atrophy of frontal/temporal lobes; abnormal proteins (e.g., tau or TDP-43).

Risk Factors: Younger onset (commonly 45–65 years), family history.

Progression: Faster decline than Alzheimer’s disease.

Possible Warning Signs of Dementia
Frequent forgetfulness, especially of recent events

Difficulty with common tasks (e.g., cooking)

Forgetting common words

Becoming lost in familiar areas

Poor judgment, especially with finances

Misplacing objects in unusual places (e.g., puts clothes

in bathtub, puts purse in oven)

Changes in mood, behavior, or personality

Lack of interest/involvement in life activities

Delirium
A syndrome (group of symptoms) that occurs relatively
acutely and is often called acute confusion—unlike
dementia, which is characterized as chronic confusion.
Delirium typically develops over a period of hours or
days and is caused by some other underlying medical
problem.

Delirium can present with a hyperalertstate (in which the

person attends to all environmental stimuli
simultaneously), hypoactive state (in which the patient
seemingly retreats into inner thoughts and experiences
that are abnormal), or mixed presentation.
Common Causes of Delirium in Older Adults

Inadequate or Fluid/electrolyte
inappropriate pain imbalance
control
Hypoxia
Fecal impaction
Head trauma
Medications

Infections (urinary,
• Treatment of delirium?
respiratory, skin)

Hypo/hyperglycemia
Depression
Higher risk for older adults with chronic illnesses,
including dementia.

Often not as obvious or as easily diagnosed as in

young or middle-aged adults. Older adults may
deny depression due to the stigma of mental illness
association.

Many older adults do not meet the strict criteria for

a diagnosis of major depression, and yet have
significant depressive symptoms.
Diagnostic Criteria for Major Depression
(DSM-IV and ICD-10 Criteria)
At least five of the following symptoms for • Fatigue/loss of energy
at least 2 weeks:
• Feelings of worthlessness/guilt
• Depressed mood*
• Impaired concentration
• Diminished interest or pleasure*
• Recurrent thoughts of death or suicide
• Significant involuntary weight loss/
gain or appetite change *Must have one of these symptoms

• Insomnia/hypersomnia The symptoms must cause significant distress or

impaired function and cannot be better
• Psychomotor agitation accounted for by other medical conditions,
substances, or bereavement.
Example Models of
Dementia Care
Progressively Lowered Stress Threshold (PLST)
Enablement
Antecedent-Behavior-Consequence (ABC)
Progressively Lowered Stress Threshold

This model of Hall and Buckwalter (1987) focuses

on the relationship between environmental stimuli
and the lowered stress threshold of the person with
dementia, identifying common stressors that may
lead to behavioral and psychological symptoms—
for example, misleading or inappropriate stimuli;
excessive external demands; physical stressors; and
changes in the environment, routine, or caregiver.
Enablement

This model focuses on supporting the remaining

abilities of the person with dementia in order to avoid
excess disability. Example, when abilities are still
present, like self-feeding, nurses focus on promoting
the use of the retained abilities (e.g., setting up the meal
tray for the client).

When abilities have been lost due to progressive

dementia (e.g., spilling while drinking), nurses focus on
assisting the client and manipulating the environment
to support the client (e.g., providing a straw).
Antecedent-Behavior-Consequence

Using the ABC model, first observe and describe your

client’s behavior.

Next, identify the antecedents or “triggers that

occurred before the behavior. Example triggers are:
discomfort or embarrassment (e.g., bathing, toileting), or
misinterpreting environmental cues (e.g., a misplaced
personal item must have been stolen).

Finally, consider the consequences or reactions that

may have worsened the behavior (e.g., yelling at the
person).
 Principles for Safe and
Effective Care
Providing safe and effective care for persons with dementia
requires understanding their unique needs and cha%enges.

Here are basic guiding principles in nursing care for

older adults with dementia:
Person-Centered Care

Treat the individual, not just the disease.

Understand their preferences, values, and life
history.

Build trust and rapport to create a supportive

environment.

Use the person’s name and engage in familiar

activities to promote a sense of identity.
Safety and Risk Reduction

Environment: Ensure a safe, clutter-free environment

with adequate lighting and minimal distractions.

Fall Prevention: Use non-slip footwear, grab bars,

and remove tripping hazards.

Wandering Safety: Provide secure areas for safe

wandering and use alarms or monitoring systems as
needed.

Minimize the risk of harm by avoiding physical or

chemical restraints unless absolutely necessary.
Communication Techniques

Use clear, simple, and calm language.

Speak slowly and allow time for the person to

process and respond.

Non-verbal cues: Smile, maintain eye contact, and

use gentle gestures.

Avoid arguing or correcting; instead, redirect or

validate their feelings.
Promoting Independence

Encourage participation in daily activities like

dressing, eating, or grooming with appropriate
assistance.

Use step-by-step instructions and cues to help the

person complete tasks.

Adapt tools (e.g., utensils with grips) to make tasks

easier.
Nutrition and Hydration

Monitor for signs of malnutrition or dehydration.

Offer small, frequent meals and easy-to-eat finger
foods.

Create a calm dining environment, avoiding

distractions.

Assist with feeding if necessary, while maintaining

dignity.
Behavior Management

Identify triggers for agitation, aggression, or

anxiety (e.g., pain, boredom, or overstimulation).

Address unmet needs (e.g., hunger, toileting, or

discomfort).

Use distraction or redirection for challenging

behaviors instead of confrontation.
Cognitive and Sensory Support

Provide structured routines to reduce confusion

and promote stability.

Use memory aids (e.g., labels, calendars, and

photos) to enhance orientation.

Engage in meaningful activities (e.g., music, art, or

reminiscence therapy) to stimulate the mind.
Emotional Support

Recognize and validate feelings of fear, frustration,

or sadness.

Provide reassurance and a calming presence during

moments of distress.

Encourage family involvement and foster a sense of

belonging.
Holistic Assessment and Care

Regularly assess for pain, changes in cognition, and

signs of infection or discomfort.

Manage comorbidities, including medications, to

avoid polypharmacy or side effects that worsen
symptoms.

Collaborate with other healthcare professionals for

comprehensive care.
Support for Family Members

Educate family members about dementia, its

progression, and effective communication
strategies.

Encourage connection with community resources.