COGNITIVE IMPAIRMENT AND DEMENTIA

Cognitive impairment and dementia are among the issues most important public health in developed countries.

Until recent years, mild cognitive impairment to be related to the aging process itself and was detected in advanced stages of disease. Today, it was determined that these patients be evaluated increasingly early stages and therefore achieves influence the course and the social environment of the patient and family.

Mild cognitive impairment is the physiological if functional impairment is dementia.

Since the middle of last century, Kral, proposed the clinical concept of benign neglect of the elderly as an isolated disturbance of memory, then other authors have developed various nomenclatures such as memory impairment associated with age. Finally, in the late nineties arises the concept of mild cognitive impairment defined by Petersen, outlining the various subclasses and is currently the most used.

The term "mild cognitive impairment" refers to a clinically apparent intellectual decline, but carries no apparent functional disability

COGNITIVE IMPAIRMENT ASSESSMENT. ROLE OF NURSING

For evidence of cognitive decline if there really is necessary to know the existing cognitive losses in normal aging ie baseline.

The lack of pathology changes in the healthy individual are:

-          Memory: affects working memory, episodic free recall, whereas iconic memory (short-term), recognition, cued recall, semantic memory, implicit and prospective remains preserved.

-          Language: deteriorates thnaming e and verbal fluency decreases, but retains the syntax and lexicon.

-          Reasoning, problem solving skills and speed of information processing decline with age.

-          Care is preserved.

ALZHEIMER

Is a progressive disorder of the brain, characterized by degenerative changes cellas cortical nerve and brain nerve endings. This process produces an irreversible deterioration of memory and intellectual functions destruction.

The background cause is unknown, the shuffled causes are autoimmune disease, a virus, genetic disease and neurotransmitter deficiency. The main risk factor is age, the eating is insidious, can affect individuals of up to 40 years, the disease progresses until the total disability.

It affects both men and women.

The occurrence and severity of signs and symptoms will vary between individuals, is characterized by loss of memory, intellectual impairment and personality change. It is classified into three stages: initial, medial and final phase. Initial indications are mild, but the main sign is the loss of short term memory, the diagnosis can take years and even diagnosed in the next stage of the disease.

In the middle stage the patient have trouble recognizing objects and things, for activities or to implement skills before or had to communicate.

In the final stage are absent memory and brainpower. In the final stage the patient is in a vegetative state

Guidelines to improve communication between nurses and patients with Alzheimer

1.      Use short words and simple sentences

2.      Repeat your statements

3.      Avoid unusual expressions

4.      From indications using fewer words

5.      Ask questions if and when patients have difficulty responding

6.      Make distracting noises disappear.

They can be both positive and negative

1.      A smile communicates happiness

2.      The frown communicates sadness or displeasure

3.      The folded arms can communicate displeasure

4.      Fast speed communicates impatience.

Be aware of facial expressions

1.      The patient may have trouble understanding facial expressions

2.      Be always aware of the expression on his face

3.      Always approach the patient with a smile.

Catching the eye of a patient

1.      You may need to grab the attention of a patient, but do not want to alarm

2.      Touch the patient gently on the arm or hand to get his attention

3.      Remember to be gentle or else his touch can alarm you

Look into the eyes

1.      The patient may feel uncomfortable when someone is standing above it or if the patient is lying

2.      Mireles in the eyes and make sure you live up to these when speaking with them

3.      Look at the patient's knees or sitting if you need them to be at their level

ASSESSMENT BY GORDON MARYORY FUNCTIONAL PATTERNS

Specific patterns are to be used for dementia. He assesses obtaining a comprehensive view of patient identifying health problems to establish appropriate care plan.

To conclude this article  se need to know that there is a need to ensure people with dementia have the best, compassionate care and support from all nurses and their teams. All nurses can make a contribution across the dementia pathway, irrespective of provider, whether it’s within the NHS, social, private, voluntary or prison sectors. 

This support starts right from keeping well, awareness raising and reducing social stigma, through to early identification, diagnosis, maintaining health and wellbeing and finally end of life care and bereavement support for carers and their families.

BIBLIOGRAPHY:

- Nursing Times; [quoted the 25/04/13]; http://www.nursingtimes.net/nursing-practice/clinical-zones/older-people/cognitive-assessment-of-older-adults-with-alzheimers-disease/201662.article

-Sonoma;[quotes the 25/04/13]; http://www.sonoma.edu/users/k/koshar/n340/N345_Gordon_FHP.html

- R.C.Petersen; Mild cognitive impairment as a diagnostic entity; Journal of Internal Medicine 2004; 256: 183–194, available in: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2796.2004.01388.x/full

AGING AND IMMOBILITY

Mobility or ability to move in the medium surrounding the individual, it is essential to have autonomy, being an essential component of human life.

The immobility can be defined as decreased ability to perform activities of daily living impairment of motor functions.

It can be distinguished:

-       A relative immobility, in which the old man leads a sedentary life but is able to move with more or less independence

-       An absolute immobility involving chronic bed rest, being very limited postural variability.

Immobility increases with age:

-       The 18%> age 65 have trouble getting around without help from 75 years and over 50% have trouble leaving home, of which 20% are confined to their homes.

-       To understand the importance of severe functional impairment involving the immobilization suffice it to say that 50% of the elderly who die acutely immobilized within six months.

Causes in Elderly Patients Immobility.

-       Physiological changes with aging.

-       Frequent Illness

-       Social factors.

-       Environmental causes

Complications Associated Immobility.

-       After prolonged immobility are changes in the various organs and systems also tend to perpetuate the syndrome. Affected systems are the most important cardiovascular and musculoskeletal, although affecting most organ systems.

-       Its impact on the prognosis of the old assets may be more relevant than the underlying disease itself, can appear even after short periods of bed rest.

Management by Nursing Immobility

-       A) Plan of action

-       B) General care of disabled patients

-       C) Prevention of complications.

Progressive Approach to Mobility

Patient Lodging

Sitting In a Chair.

Standing

Ambulation

Maintenance

People at Risk Of Syndrome Immobility

Two groups must identify:

Aged sedentary that is one who has incorporated into its everyday activity vigorous physical exercise, clearly impact on energy consumption.

Frail elderly (From the perspective of mobility), it is one that has limited extra activities, while maintaining an appropriate level for community living. It has just enough functional reserve and strength, muscular endurance and flexibility scarce. It usually coexist various geriatric syndromes

The primary care physician should periodically assess functional abilities in these two groups of elderly and those who have recently been discharged from hospital. 

Finally as far as nurses are concerned, Nursing's role is coordinating ambulation activities, enabling staff to recognize residents' ambulation potential, teaching staff methods of improving participants' self-esteem, and encouraging staff to ambulate residents as part of daily activities, such as using the bathroom and walking to the dining room.

To improve the success of a walking program, be sure to educate staff on the benefits of walking and include the nurse aides in interdisciplinary conferences to develop effective individualized approaches. It may be helpful to have start and stop points for the ambulation route of residents, changing the distance walked according to individual need. Facilities have also found success in providing rewards for the residents' accomplishments, such as offering a favorite food or presenting a certificate or recognition.

BIBLIOGRAPHY:

-Inmobility problemas and solutions,  Intentional Caregiver; [quoted the 24/04/13] Available in: http://www.intentionalcaregiver.com/immobility-problems-and-solutions/

- Physiological Changes Associated Whit Aging and Inmovility, Journal of Aging Research Volume 2012 (2012), Article ID 468469; Available in: http://www.hindawi.com/journals/jar/2012/468469/

- Margareta Lindgren, Mitra Unosson, Mats Fredrikson, Anna-Christina; Immobility – a major risk factor for development of pressure ulcers among adult hospitalized patients: a prospective study; available in: http://liu.diva-portal.org/smash/record.jsf?pid=diva2:242329

- HOFFMAN, Gloria Basic Geriatric Nursing 5th Edition. Elsevier 2012. 

ULCERS FOR PRESSURE

The Ulcer by Pressure (UP) can be defined as any area of hurt in the skin and underlying fabric caused by the pressure prolonged on a hard plane, not necessarily intense, and independent from the position.

 It is a common problem in the care of the patients with chronic diseases, especially in elders with limited mobility, with important morbidity and mortality and high economic and social repercussion.

The most important thing is that 95 % of the UP is avoidable and for it there is prior the prevention based fundamentally on methods that quantify factors of risk and that help to predict the affectation of the fabrics.

The most important factor in the development of the UP is the supported pressure. With her parallel and / or tangential forces of friction can be associated, as well as a series of factors of risk that depend fundamentally on the conditions of the patient.

 The UP need the existence of disorders of the micro traffic in zones of support of the body placed on a hard surface. For this motive the areas with bony prominences are the most frequent zones of UP's appearance.

RISK FACTORS

1 path physiological

2 derived from the treatment:

3 of environment

4 Situational

 CLINICAL ASSESSMENT

The pressure ulcers do not heal unless the underlying causes are effectively addressed. A comprehensive assessment must include the identification and effective treatment of the disease, health problems, nutritional status, degree of pain and the psychosocial aspects that may have located the person at risk for developing pressure ulcers.

NORTON PREASURE ULCER SCALE

REVIEW

* Score of 5 to 9: very high risk •

* Score of 10 to 12: high risk •

* Score of 13 to 14: medium risk •

* Score greater than 14: minimal risk/no risk

VALUATION OF THE INJURY: ESTADIAJE

Stadium I: (degree 1) intact Epidermis, adherent and eritem that does not disappear when the pressure eliminates

Stadium II: (degree 2) Sore with aspect of grazes flictena or crater slightly deep

Stadium III: (degree 3) total Loss of thickness of the skin with injury or necrosis of the subcutaneous fabric, being able to spread up to the underlying fascia but without crossing it. If there is affectation of the fascia already it belongs to a stadium the IVth.

Stadium  IV: It concerns the muscle and can come to the bone. Total loss of the thickness of the skin with necrosis of the fabric or muscular, bony hurt or of structures of support (tendon, capsule to articulate, etc.). Also it can associate to a hole and tracts fistula in the adjacent fabric.

DIAGNOSIS OF INFECTION

Diagnosis of wound infection is primarily based on clinical criteria. The valuation must understand the assessment of the patient, of the tissues surrounding the wound and the wound itself for signs and symptoms of infection, as well as on factors that are likely to increase the risk and severity of the infection.

OVERALL MEASURES OF TREATMENT

1. - Implement protocols

2. - Unify care

3. - treatment based on scientific evidence

4. - Make decisions based on cost/benefit

To conclude and in a nursing point of view we must know that pressure sores, also called decubitus ulcers or bed sores, are a big problem in hospitals, nursing homes and patient homes. Pressure ulcers are areas where the skin has broken down. They can go very deep to the bone. Pressure ulcers can cause pain and very serious infections that can lead to death.

Pressure ulcers make a hospital stay longer than it should be. They raise the costs of patient care. Most pressure ulcers result from the lack of mobility. Patients and residents who stay in the bed or a chair are at high risk for pressure ulcers. Nursing assistants and other healthcare workers can prevent them. We must prevent pressure ulcers with proper skin care, by looking at the patient and their skin, by giving our patients a good diet and a lot of fluids, by helping them walk, and by turning and positioning them often. 

BIBLIOGRAPHY:

1.NHS Choices; [quoted the 23/04/13] and available in:
 http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Introduction.aspx

2.Nursing homes abuse blog; [quoted the 23/04/13] and available in:
http://www.nursinghomesabuseblog.com/bedsores-pressure-sores-decubitus-ulcers/sepsis/understanding-pressure-sores-in-nursing-homes-other-medical-facilities/

3. - HOFFMAN, Gloria Basic Geriatric Nursing 5th Edition. Elsevier 2012. 

GENERAL ASPECTS OF THE DISEASES IN THE ELDERS

GENERAL ASPECTS OF THE DISEASES IN THE ELDERS

1. The heterogeneity of the 65-year-old major population: healthy elder, sick, elderly fragile elder and patient geriatric

2. The peculiarities of the diseases in the same: atypical presentations of the diseases

3. The fragility like scoreboard of vulnerability in the major persons.

4. Pluripatology and polydrugstore: several diseases can concern to different organic or related systems or not between if.

5. They meet favored by some factors: alteration of the aptitude to keep constant the internal way, interaction of a few systems with others, long periods of latency of many diseases up to becoming symptomatic, inmunitary alterations and yatrogenia. The increase of the consumption of medicaments that is in the habit of being a consequence of the consumption of medicaments that is in the habit of being a consequence of the previous thing and, in occasions, inevitably, being frequent the yatrogenia.

6. Trend to the time and frequent disability: discharge prevalence of chronic and degenerative diseases, which originate dependence with overload of the keepers and high percentage of institutionalizations

7. I predict less favorable of the diseases: these agree in an organism with less functional reservation and capacity of response to you will put stress day pupils, not justifying the abstinence it diagnoses and the opportune treatment, since we verify daily that a sick good diagnosed and agreement answers better than we would wait.

8. Difficulties you diagnose and therapeutic: so much the attitudes you diagnose like therapeutic in geriatrics risk / benefit must be guided by the binomial always looking for this one I finalize, having in the opinion of the elder tells and always after a correct geriatric integral valuation that it should justify to realize or not certain measures you diagnose or therapeutic.

9. Major utilization of sanitary resources: the elders are big consumers of sanitary resources. Demand it hospitable it is characterized for:

a. Hospitable double rate of income to that of the general population, being the triple one that of the major group of 80 years

b. Prolongation of the hospitable stay in many cases tied to the major dependence and yatrogenia in these patients

c. Great number of reentries.

General aspects:

- Trend the time

- Major consumption of sanitary resources - Is Predicted by Me less frequent

- Pluripatology and polydrugstore

- Heterogenic and fragility

10. Major need of rehabilitation (tertiary prevention): the reasons of functional deterioration in an elder can be: multiple, accumulative and interactive; being, on the other hand in this population group where with more frequency diseases affect disability. One of objective you of the geriatrics will be the maintenance of the autonomy and the function across the use of the precocious rehabilitation that was forming a part of the global plan of integral treatment of the elder. A bed-ridden patient has a forecast of life lower than 6 months.

11. Frequent need of utilization of social resources: and the elder often the appearance of disease makes emerge or aggravates problems in society and family.

12. Frequent ethical problems: in capture of decisions you diagnose and therapeutic in the final stadiums of the life, stretching of the life of artificial form in absence of a vital testament of the individual, legal incapacitations in persons with dementia.

What must the professional of infirmary know on the effects of the pain in the geriatric patient?

- Depression

- Decrease of the socialization - Alterations of the dream

- Upset movement.

- Increase of costs and utilization of services of health

- Many conditions deteriorate, including disorders of march, slow rehabilitation and adverse effects d and multiple prescriptions health care.

Effects of the Pain in the patient Geriatric. SCALE, EVE

It consist in a straight, horizontal or vertical line of 10 cm, his ends are delimited by brands that express: without pain and worse possible or imaginable pain it is asked the patient to mark a point in the line that reflects his pain the distance measures up in millimeters from the end not pain up to the marked point The EVE would have a major sensibility for having an infinite number of points between both ends.

11. CHARACTERISTICS OF THE GERIATRIC SYNDROMES

1. Multiorganic affectation or pluripatology

2. The reason is due to some reasons.

3. Restoration and rapid progress of the disease

4. Slightly expressive with clinical minimal manifestations or silences’ and sometimes contraindications

5. It is very sensitive to the infections, to the changes of temperature dehydrations, anemia, malnutrition, accidents

6. Major severity as for the intensity of the hurt skin and complications

7. Irreversibility of the loss of the organic function mincingly of the mobility; syndrome of immobility

8. Slow paces of treatment, trend to the time

9. The adaptative answers of the organs can unleash new symptoms.

10. Apathy, depression and mental confusion produces

11. Acceptance of the disability on the part of the patient and the family

12. Answers of iatrogenic type

13. Denial of symptoms (he complains little)

14. Present some type of social or familiar problem.

15. The slightly favorable forecast

To sum up we must know that an aging-associated disease is a disease that is seen with increasing frequency with increasing senescence. Essentially, aging-associated diseases are complications arising from senescence. Age-associated diseases are to be distinguished from the aging process itself because all adult animals age, save for a few rare exceptions, but not all adult animals experience all age-associated diseases. Aging-associated diseases do not refer to age-specific diseases, such as the childhood diseases chicken pox and measles. "Aging-associated disease" is used here to mean "diseases of the elderly". Nor should aging-associated diseases be confused with accelerated aging diseases, all of which are genetic disorders.

BIBLIOGRAPHY: 

- Chou KL, Chi I; Reciprocal relationship between pain and depression in elderly Chinese primary care patients.Int J Geriatr Psychiatry; 2005 Oct;20(10):945-52.

- HOFFMAN, Gloria Basic Geriatric Nursing 5th Edition. Elsevier 2012.