Chapter 8 Learning Objectives 

At the conclusion of this chapter, students will be able to:

Urinary tract infections (UTIs) are a type of infection common among older people. A urinary tract infection is usually caused by bacteria entering the urinary tract via the urethra – the tube that allows the passage of urine from the bladder to outside the body. If an older person has a sudden and unexplained change in their behaviour, such as increased confusion, agitation, or withdrawal, this may be because of a UTI. If a person with a memory impairment or dementia has a UTI, this can cause sudden and severe confusion, known as ‘delirium.’ The person may not be able to communicate how they feel; therefore, it is helpful to be familiar with the symptoms of UTIs and seek medical help to ensure they get the correct treatment.

It is also important to be aware that any infection could speed up the progression of dementia, so all infections should be identified and treated quickly. If treated with the right antibiotics, UTIs normally cause no further problems, and the infection soon passes (Alzheimer’s Society, n.d.).

Maintaining adequate nutrition and hydration plays a vital role in preventing and treating delirium and other conditions. It may be appropriate to consider enteral feeding via a nasogastric tube if the patient is unable to eat and drink enough to meet their nutritional needs. Functional dysphagia is a common side effect of delirium. Enteral feeding can improve intake and prevent poor clinical outcomes. However, the risks of tube feeding, and its placement must be weighed against the benefits of adequate nutrition. Enteral feeding may cause additional stress for the patient.

Decision-making about enteral feeding for a patient with delirium is complex and must be individualized in line with patient goals and the prognosis of the underlying conditions. Appropriate patient positioning remains important to reduce the risk of aspiration, such as sitting upright at a 45-degree angle (Park et al., 2013). In addition, using bolus rather than continuous feeds may be more appropriate to reduce restraint utilization and address limitations to mobility. Strategies to reduce the risk of dislodgement include using fiddle blankets and other distracting activities. If it is safe, continuing to provide even tiny amounts of oral intake when the patient is more alert and able to sit upright will help promote swallow function and appetite, provide pleasure, and maintain meaningful routines. The feeding tube should be removed as soon as adequate oral intake can be re-established (Geirsdóttir & Bell, 2021).

Dementia is the umbrella category used to describe the general long-term and often gradual decrease in the ability to think and remember that affects a person’s daily functioning. The manual used to help classify and diagnose mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, or DSM-V, classifies dementia as “major neurocognitive disorder, with milder symptoms classified as “mild cognitive impairment,” although the term dementia is still in common use. Common symptoms of dementia include emotional problems, difficulties with language, and decreased motivation. A person’s consciousness is usually not affected. In North America, about 10% of people develop the disorder at some point, and it becomes more common with age. As more people are living longer, dementia is becoming more common in the population.

Dementia refers to severely impaired judgment, memory, or problem-solving ability. It can occur before old age and is not inevitable, even among the very old. Numerous diseases and circumstances can cause dementia, resulting in similar general symptoms of impaired judgment, etc. Alzheimer’s disease is the most common form of dementia and is incurable, but there are also nonorganic causes of dementia that can be prevented. Malnutrition, alcoholism, depression, and mixing medications can also result in symptoms of dementia. If these causes are properly identified, they can be treated. Cerebral vascular disease can also reduce cognitive functioning.

Alzheimer’s is a progressive disease that causes problems with memory, thinking and behaviour, and is the most common cause of dementia. Symptoms usually develop slowly and worsen over time, becoming severe enough to interfere with daily tasks (Alzheimer’s Association, n.d.).  During the preliminary stages, memory loss is mild. In later stages it becomes more severe, and individuals lose the ability to carry on a conversation and respond to their environment. Alzheimer’s is not a normal part of aging, but increasing age is the greatest known risk factor. On average, a person with Alzheimer’s lives 4-8 years after diagnosis but can live as long as 20 years, depending on other factors (Alzheimer’s Association, n.d.).

The most common early symptom is difficulty remembering recent events or newly learned information. Alzheimer’s changes typically begin in the part of the brain that affects learning. As the disease advances, symptoms can include problems with language, disorientation (including easily getting lost), mood swings, loss of motivation, not managing self-care, and behavioural issues. In the initial stages, memory loss is mild, but with late-stage Alzheimer’s, individuals lose the ability to carry on a conversation and respond to their environment. People with memory loss or other signs of Alzheimer’s may find it hard to recognize that they have a problem. Signs of dementia may be more evident to family members or friends. Anyone experiencing dementia-like symptoms should see a doctor as soon as possible. Earlier diagnosis and intervention methods are improving dramatically, and treatment options and sources of support can improve quality of life.

Microscopic changes in the brain begin long before the first signs of memory loss. Scientists believe Alzheimer’s disease impedes parts of a brain cells’ functional ability. Scientists are unsure where the trouble starts, but issues in one part of the cell cause issues in other areas. As damage spreads, cells lose their ability to do their jobs and eventually die, causing irreversible changes in the brain Two abnormal structures called plaques and tangles are prime suspects in damaging and killing nerve cells. Plaques are deposits of a protein fragment that build up in the spaces between nerve cells. Tangles are twisted fibers of another protein that build up inside cells. Microscopic changes lead to physically observable changes, as depicted in Figure 9.3.2. Autopsy studies show that most people develop some plaques and tangles as they age; however, those with Alzheimer’s tend to develop far more and in a predictable pattern, beginning in the areas important for memory and then spreading to other regions. The destruction and death of nerve cells causes memory failure, personality changes, problems carrying out daily activities and other symptoms of Alzheimer’s disease. Alzheimer’s has no cure, but treatments can temporarily slow the worsening of dementia symptoms and improve the quality of life for those with Alzheimer’s and their caregivers.

A person with Alzheimer’s needs special care, providing a safe environment. They may wander and end up in an unknown place with no memory of who they are, how they got to where they are, or how to return home. It is also important to prevent dangerous events such as fires, as a person with Alzheimer’s may begin to cook and forget they have food on the stove. Writing lists and labelling objects throughout the house may also be helpful to remind a patient with Alzheimer’s disease what the objects are. It may even helpful to place a note on the mirror with the patient’s name or a label such as “Myself” if they are at the point where they no longer remember who they are. Caregivers should remember to be patient and encouraging and find the things that seem to bring comfort and do these things with their patients. Many patients with Alzheimer’s enjoy music, and caregivers or relatives can try playing some to help their patients relax and find enjoyment.

Late afternoon and early evening can be difficult for some people with Alzheimer’s disease. They may experience sundowning—restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade—often just when tired caregivers need a break. Sundowning can happen at any stage of dementia but is more common during the middle stage and later stages (Alzheimer’s Society, n.d.). Although the exact cause of sundowning is unknown, these changes result from the disease’s impact on the brain. The mental and physical exhaustion from trying to keep up with an unfamiliar environment may contribute to difficulties in sleep. Disorientation due to the inability to separate dreams from reality is another factor that may contribute to this phenomenon of sundowning.

Some research suggests that a low dose of melatonin — a naturally occurring hormone that induces sleepiness — alone or in combination with exposure to bright light during the day may help ease sundowning. Tips that may help to manage sundowning include scheduling activities in the morning when the person with dementia is more alert rather than at night, encouragement of a regular routine of waking up and going to bed, when possible, and including walks or time outside in the sunlight.

Parkinson’s disease is a progressive and incurable disease of the brain (according to National Institute of Aging) resulting in permanent changes. This condition results from the depletion of dopamine in the brain causing abnormalities in cells deep within the brain tissue. People with Parkinson’s have difficulty initiating movement, such as walking, and have tremors, making it difficult to perform daily tasks such as feeding and dressing. Muscles will become stiff, and the person may have a shuffling gait or be unable to walk. Dementia may occur as Parkinson’s progresses. The cause of Parkinson’s disease, and the depletion of dopamine, is unknown, but treatments for this condition focus on replacing dopamine levels in the brain.

Cardinal signs of someone experiencing Parkinson’s include tremors, rigidity, bradykinesia, and postural instability. As Parkinson’s disease progresses in a patient, it is common to see them experience dysphasia, soft monotone speech, and changes in gastrointestinal motility. Being patient and encouraging is important when caring for patients with Parkinson’s. It is frustrating for them to be unable to care for themselves. Encourage them to do as much as possible and assist them with Activities of Daily Living (ADLs) as needed.