Change in Cognition of the Elderly Essay

Change in Cognition of the Elderly Essay

 Change in Cognition of the Elderly Essay

Cognitive decline has a high prevalence in the elderly and increases with aging. Dementia is characterized by an overall decline in memory and other cognitive skills, which can be severe enough to impair an individual’s capacity to carry out activities of daily living (ADLs). Persons with dementia face cognition, behavior, and functional challenges. The purpose of this paper is to discuss signs of cognitive decline or dementia in a patient on a home health visit. The paper will also discuss risk assessments and cognition screening tools, approaches used to address agitation, distress, and challenging behaviors, and identify resources and services in Sentinel City.

Pertinent Observations and Subjective and Objective Signs of a Decline in Cognition or Dementia

Anna presents with signs of cognitive decline such as memory loss and shortened attention span. The signs are demonstrated when she offers the nurse some coffee, but she forgets this and later asks the nurse if she would like coffee. She also asks repetitive questions when the nurse is demonstrating wound care. Anna also forgot some words and the nurse’s reason for the visit. Confusion is also apparent, as evidenced by Anna’s confusion about the month (Porsteinsson et al., 2021). Anna also tries to locate her eyeglasses, yet they are on the table next to her. Besides, Anna had kept the leftover foods in the microwave instead of the refrigerator.   Difficulties recognizing family members and familiar faces is another sign of cognitive decline present in the patient (Porsteinsson et al., 2021). Anna could not recall the names of all her grandchildren in the photo. She also fails to recognize a familiar face, the home health aide, whom she confuses as someone coming to help around the house.

Anna has a loss of spontaneity and sense of initiative, which occurs in dementia. The nurse notes that Anna demonstrates less initiative to hold conversations. Another sign of dementia present is the loss of impulse control seen when Anna pulls up both of her pant legs, showing a soiled bandage on her wound, and when she tears off the bandage (Porsteinsson et al., 2021). Moderate cases of dementia present with agitation, restlessness, anxiety, irritability, and tearfulness. Anna becomes irritable and tearful and even declines the nurse’s assistance. Lack of bowel and bladder control occurs in severe cases of dementia (Porsteinsson et al., 2021). Anna uses adult diapers, and the nurse notes that she has urgency, frequency, and incontinence. Furthermore, dementia presents with a reduced ability to carry out ADLs. This is evident in Anna based on her untidy and stinking house, unwashed dishes, poor grooming, and soiled bandage.

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Risk Assessments and Cognition Screening Tools for an Individual Experiencing a Decline in Cognition

Appropriate risk assessments and cognition screening tools for persons with cognitive decline include the Montreal Cognitive Assessment. It is a psychometric test of memory, language, executive function, and praxis designed to detect cognitive decline. The Mini-Cog is another psychometric tool for memory, language, executive function, and praxis that uses a clock draw and a 3-word recall test (McCollum & Karlawish, 2020). The Memory Impairment Screen is a brief psychometric delayed and cued recall test that can assess the risk of cognitive impairment. Furthermore, the provider can administer the Mini-Mental State Examination (MMSE), a psychometric test for memory, orientation, attention, language, and praxis (McCollum & Karlawish, 2020). The Hodkinson Abbreviated Mental Test Score (ABTS) can assess the risk of dementia and is also used for other cognitive impairments. Scores show an individual’s current level of impairment. Individuals experiencing a cognitive decline are at risk of falls due to poor coordination and balance. Falls Risk Assessment Tool (FRAT) can be used to assess fall risk status.

Interventions Used To Address Agitation, Distress, and Challenging Behaviors

Both pharmacological and non-pharmacological approaches address agitation, distress, and difficult behaviors in persons with cognitive decline. Pharmacological measures include antipsychotics for hallucinations and delusions and anxiolytics for agitation and anxiety. Antidepressants/mood stabilizers are used for mood disorders to manage anger and irritability (Brasureet al., 2018). Non-pharmacological approaches include structured activities and sensory interventions such as light therapy. Stimulation-oriented interventions like recreational activities and music, art, or pet therapy increase pleasurable moments and improve behavior and mood (Brasureet al., 2018). Improving the patient’s environment is also a general approach to addressing challenging behaviors.

Resources and Services That Are Available To Providers, Families, and Caregivers in Sentinel City

Resources available in Sentinel City for patients, families, and caregivers in relation to cognitive decline include a senior center that provides emergency services. It also provides older adults with advice on advance directives such as living will and power of attorney. There are also church groups for seniors which facilitate tours and bus rides, which is a form of therapy. Anna could benefit from the senior center and church groups where she can interact with other seniors alleviating boredom and behavioral problems.

Conclusion

Anna presented with clinical features of dementia, including memory loss, shortened attention span, confusion, loss of initiative, difficulties recognizing familiar faces, loss of impulse control, irritability, limited ability to perform ADLs, and loss of bladder and bowel control. Cognitive decline can be assessed using Montreal Cognitive Assessment, Mini-Clog, Memory Impairment Screen, MMSE, and ABTS. Behavioral problems can be addressed using medications and non-pharmacological interventions.

References

Brasure, M., Jutkowitz, E., Fuchs, E., Nelson, V. A., Kane, R. A., Shippee, T., … & Kane, R. L. (2018). Nonpharmacologic interventions for agitation and aggression in dementia.

McCollum, L., & Karlawish, J. (2020). Cognitive Impairment Evaluation and Management. The Medical clinics of North America, 104(5), 807–825. https://doi.org/10.1016/j.mcna.2020.06.007

Porsteinsson, A. P., Isaacson, R. S., Knox, S., Sabbagh, M. N., & Rubino, I. (2021). Diagnosis of early Alzheimer’s disease: clinical practice in 2021. The journal of prevention of Alzheimer’s disease, 8(3), 371-386. https://doi.org/10.14283/jpad.2021.23

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Overview
A normal part of the aging process includes a mild decline in some areas of cognition. Many older adults experience changes in immediate memory or the ability to name objects but not all cognitive changes are considered a normal part of the aging process. Individuals with cognitive decline diagnosed with dementia often experience unmet needs that include hunger, pain, and toileting. This activity will provide students the opportunity to gain an understanding of normal versus abnormal changes in cognition and identify nursing and collaborative interventions to minimize the impact of cognitive impairment, including safety concerns, and to optimize resources and services.
1. Review the home health visit notes below to differentiate normal versus abnormal age-related changes. Record pertinent observations and subjective and objective signs of a decline in cognition or dementia.

2. Suggest risk assessments and cognition screening tools for an individual experiencing a decline in cognition, such as a mini mental status exam and fall risk assessment.

3. Discuss interventions used to address agitation, distress, and challenging behaviors in an individual with a decline in cognition.

4. Describe resources and services that are available to providers, families, and caregivers in Sentinel City® to assist with a decline in cognition. List resources in your community that could benefit Anna.

*** HOME HEALTH NOTES***
Home Health Visit Notes
After reviewing the baseline information on Anna in Sentinel City®, read the notes below of the RN home health visits with Anna for wound care following a fall. Identify subjective and objective data and observations of normal and abnormal changes observed with geriatric or dementia patients.
Notes from Visit One
Anna welcomed the nurse into the living room where there was a pile of unfolded laundry on the couch. Anna ambulated around the room, without the use an ambulatory device. Home hazards noted include loose rug, low toilets, step over shower, shower without a bench, and stairs. Anna often wears shoes in the house supporting her feet. Anna’s last eye exam was within the last 6 months and her eyeglasses were updated. Wound care supplies are available near her chair. Anna’s glasses are sitting on the table, alongside a birthday card and holiday cards. Anna mentions how it was wonderful to see her family for her birthday. Anna offered the nurse some coffee. Anna is dressed in clean yet wrinkled clothing with her hair styled and earrings on. When asked about nutrition, she was excited to share that she had leftovers from the holidays.
Anna was confused to the month, while orientated to the day, time, and year. She laughed and said that she meant that that she had been pulling leftovers out of the freezer from the holidays for their meals. Anna mentioned that it has been too cold for her to go out like she enjoys, so she and her partner have been staying home. There are a few unwashed dishes and open soup cans on the counter, near several medication bottles. Anna reported that she has been trying to drink enough water and drinks coffee in the morning. Anna asked the nurse if she would like some coffee.

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Anna is observed walking independently with occasional loss of balance. Anna was opening curtains and moving small items around the room, trying to locate her glasses. Anna reported that she has been changing her dressing whenever it needs it and there has not been too much pain. Anna stated that she had not had any other falls since her injury. Upon assessment, the wound measurements have not improved in the last two weeks. Several layers of gauze were added, without removing the old dressing. Anna was asked to demonstrate wound care for the nurse and missed several steps. The nurse demonstrated correct wound care and provided visual instructions for Anna. Anna asked four repetitive questions to clarify process. Plan for home health aide to visit three times weekly. Nurse to visit weekly.
VS: T 98.4/tympanic; HR regular 84 bpm; Resting Respiratory rate 18. BP 112/64.
Notes from Visit Two:
Three weeks later, the nurse was alerted that Anna would not open the door to allow the home health aide in. Anna answered the door and allowed the nurse to enter. Anna walked independently to the living room and sat down in her chair. Anna knew that she was in her home, the name of her city and state. Anna did not have any medical equipment attached to her. The curtains were closed, the kitchen and living area was cluttered and unkempt and Anna appeared to have been sitting alone in the dark room. Anna was picking at her lap blanket, appeared disheveled and ungroomed. The living room smelled of urine. Adult diapers were viewed in the bathroom garbage can. The nurse identified that Anna is having urgency, frequency, and incontinence.
The birthday and holiday cards remained on the table alongside several pieces of unopened mail. Anna stated that it was wonderful to have her family come by for the holidays and take such good care of her. Anna was unable to recall the names of all her grandchildren in a photo, while naming her partner. Anna was able to state the year, season, day of the week and the date. Anna was again confused to the month.
When asked about her home health aide, she said it was nice to have more company and extra help around the house this week. Anna laughed when the nurse inquired about letting the aide in her home. Anna paused and thought about it in silence. After a minute she said there was someone handing out political papers and she told them to not come back. Anna then asked the nurse why she was there today. The nurse explained she wanted to check on her, including her bandage. Anna said that things had been fine, and she was glad to get rested after the holidays. Anna mentioned that they have not been getting together with friends in the last few weeks. It was evident that Anna is forgetting some words and is demonstrating less initiative to conversate.
The microwave kept beeping every few seconds. The nurse went to the microwave and found an uneaten breakfast plate. Anna laughed and said that she meant to put the leftovers in the refrigerator. The nurse reminded Anna of the importance of nutrition, hydration, and hygiene for her body to heal. Anna became irritable and again asked the nurse why she was there. The nurse reminded Anna that she was there to check on the bandage on her leg. Anna pulled up both of her pant legs, revealing a soiled bandage on her wound. Anna became tearful and said she changed the bandage several times. The bandage was dated three days ago by the home health aide. Anna reached down and tore off the bandage. Anna became anxious and agitated while looking at the supply table. The nurse offered to assist her with the wound care and Anna declined assistance. Anna began to cry and then allowed the nurse to provide wound care.
VS: T 97.8/ty; HR regular 94 bpm; Resting Respiratory rate 22. BP 116/66 lying flat; BP 92/ 58 standing
Notes: Review medication list, history for comorbidities and risks listed in Anna’s profile that increase her risk for falls. Does the patient take vitamin D?