Dementia is an umbrella term used to describe a decline in mental cognition that interferes with daily life. Patients with dementia experience a loss of memory, decision-making skills, and even personality traits. Symptoms can range from mild to severe. It is important to note that dementia is not a normal or expected part of aging.
Alzheimer’s disease is a type of dementia. There are many types of dementia, but Alzheimer’s disease is the most common one. Alzheimer’s disease is progressive beginning with a preclinical stage that usually doesn’t present with symptoms, though changes in the brain are occurring. The patient then progresses through mild, moderate, and severe stages, which may occur gradually over years. At this time, there is no cure for Alzheimer’s disease.
The Nursing Process
There are many nursing diagnoses related to Alzheimer’s disease and dementia. As dementia progresses it can result in self-care deficits in bathing, grooming, toileting, and feeding. Alzheimer’s disease can lead to swallowing difficulties as the patient loses their ability to swallow which can result in life-threatening aspiration pneumonia. In one study, half of the patients with dementia who were admitted to the hospital for either pneumonia or a hip fracture died within six months of discharge.
That being said, safety is a huge concern when caring for dementia patients. Falls are a common occurrence due to the loss of reasoning ability and judgment recall. They may not be able to ambulate yet will attempt to get out of bed or a wheelchair unassisted. Their memory loss may lead them to believe they need to get to work or run an errand and they will attempt risky behaviors or wander.
Nurses may treat patients for an array of physical conditions that are also complicated by dementia. Understanding the importance of safety but also the emotional and mental challenges these patients face will help the nurse provide the best care. Patients with dementia require patience and specific strategies to communicate effectively to meet their needs.
Nursing Care Plans Related to Alzheimer’s Disease and Dementia
Social Isolation Care Plan
Nursing Diagnosis: Social Isolation
- Declining cognition
- Difficulty with speech
- Personality changes (anger, inappropriately vulgar or sexual speech/behavior)
- Physical deconditioning
As evidenced by:
- Forgetting names or dates
- Repeating questions or information
- No longer able to drive
- Inability to recognize friends or family
- Needing assistance with basic self-care
- Disturbed sleep patterns
- Agitation or combativeness
- Patient will maintain meaningful relationships with friends and family for as long as possible
- Patient will seek social support through support groups, organizations, and the community to ease the burden of their disease
- Patient will maintain an active and enriched lifestyle, partaking in activities and hobbies
Social Isolation Assessment
1. Assess for a support system.
Assess for family members, friends, or other support systems such as church members or community groups that assist the patient with everyday activities and social stimulation.
2. Determine physical and mental limitations.
Assess for symptoms related to the disease that is causing isolation. Physical limitations may include an inability to ambulate or care for themselves, while cognitive limitations such as an inability to communicate or socially unacceptable behavior will prevent regular socialization.
3. Assess for mental illness barriers.
Patients may become isolated due to embarrassment in losing their memory and forgetting simple details as well as losing their independence in activities such as driving or getting dressed. They may feel hopeless, anxious, and even become depressed, further isolating them.
Social Isolation Interventions
1. Provide games and activities to their cognitive level.
Depending on the stage of their disease, provide puzzles, books, music, and exercise programs to keep their mind and body stimulated. Encourage family members to assist the patient with activities and hobbies they enjoy such as gardening or cooking, even if they aren’t able to complete tasks as they used to.
2. Refer to adult daycare centers or facilities.
Patients and families can benefit from adult daycare centers or programs for those with conditions such as Alzheimer’s disease or Parkinson’s disease that provide socialization.
3. Help them remember who they are.
Patients with dementia may become isolated from a sense of hopelessness due to a loss of their independence. Play some of their favorite music, look through family photos, or simply ask them questions about their childhood to provoke their memory and remind them of their accomplishments and purpose.
4. Get outside.
Socialization doesn’t have to be costly or difficult. Simply being in the presence of others sitting at a park provides plenty of stimulation. Being in nature, breathing in fresh air, and feeling the sun has amazing mood-boosting benefits.
Risk For Falls Care Plan
Nursing Diagnosis: Risk for Falls
- Advanced age
- Poor mobility
- Loss of perception
- Use of assistive devices
- Vision loss
- Poor balance
- Decreased coordination
- Misinterpretation of environment
- Gait abnormalities
- Medications (sedatives, antidepressants, antipsychotics)
- Caregiver strain
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred yet and the goal of nursing interventions is aimed at prevention.
- Patient will remain free from falls
- Patient will utilize assistive devices correctly to prevent falls
- Patient will call for help before ambulating or transferring
Risk For Falls Assessment
1. Perform a fall risk assessment.
Several fall risk scales can be utilized as well as other assessments to determine a risk for falls. The Morse Fall Scale is a common fall risk scale used on all hospitalized adults though it may not account for all of the risk factors in those with dementia. Research shows that patients with a high MMSE (Mini Mental Status Exam) score, which is used to test cognitive function, show a correlation between cognitive decline and falls.
2. Assess muscle strength and coordination.
Assess gait, stability, balance, gross and fine motor skill coordination, and the use of any assistive devices. Adults with dementia may overestimate their abilities or forget their limitations.
3. Assess judgment and perception.
Patients with dementia may appear lucid but have periods of forgetfulness or confusion. This occurs more often at night and is known as sundowning. This increases the risk of wandering. The nurse should reassess orientation regularly in dementia patients as the perception of their environment, ability to reason, and behaviors can shift.
Risk For Falls Interventions
1. Keep items within reach.
Water cups, eyeglasses, remote control, phone, and any frequently used items should be kept within close reach to prevent the patient from needing to move from the bed or chair to reach something.
2. Use fall alert devices.
In the hospital, bed and chair alarms should be used when a patient is identified as being a fall risk. In the home, there are also mattress and chair pads that can be used. The patient should be given a fall alert device such as a necklace to press in the event of an emergency.
3. Unclutter the environment.
For ambulatory patients, keep hallways and walking areas clear. Remove or rearrange extra furniture, remove rugs, and keep the floor free from cords. If the patient uses an assistive device this further increases the risk for a fall.
4. Consider visual acuity.
Vision issues paired with impaired cognition can lead to a misinterpretation of the environment. Poor depth perception, shadows, and glares can contribute to falls. Use night lights in hallways and bathrooms, open curtains and blinds during the day, and use lamps at night. Providing contrast is also important to help with confusion. Choose grab bars or handrails that are darker than the wall, if floors are dark, opt for light-colored furniture, and limit the use of patterns.
Self-Care Deficit Care Plan
Nursing Diagnosis: Self-Care Deficit
- Cognitive decline
- Impaired Judgment
- Poor decision-making
- Inability to communicate needs
- Declining motor skills
As evidenced by:
- Transferring or ambulation difficulties
- Inability to safely prepare food
- Inability to handle utensils
- Swallowing difficulties
- Lack of judgment in clothing choices (shorts in winter, scarf in summer)
- Difficulty in dressing self
- Re-wearing dirty clothing
- Inability to safely regulate water temperature for bathing
- Inability to recognize urge or remove clothing for elimination
- Needing reminders or coaching to complete tasks
- Inability to maintain hygiene (unbrushed hair or teeth, unshaven face, body odor)
- Patient will maintain independence in dressing, bathing, and toileting for as long as possible
- Patient will prepare meals and feed themselves within their abilities to maintain safety
- Patient will alert their caregiver to needs (requesting a drink, needing to use bathroom)
Self-Care Deficit Assessment
1. Assess their level of abilities.
Observe the patient to assess their physical and mental capabilities. Dementia patients may try to hide their loss of self-care or may be unaware of the extent of their loss of decision-making. Assess for safety concerns, errors in judgment, or areas to enhance and support their self-care activities.
2. Determine caregiver support.
Caring for those with dementia can be time-consuming and exhausting for family members. Assess family and caregivers to ensure they understand how to support their loved one at home. Suggest paid caregiver support if needed or refer to community resources that offer volunteers or equipment needed in the home.
Self-Care Deficit Interventions
1. Maintain a schedule and routine.
The family or caregiver should encourage a routine each day that includes dressing, bathing, meal times, and elimination practices. This prevents confusion and helps the patient maintain organization and independence.
2. Offer simple choices.
Patients with dementia can often become overwhelmed when making decisions and cannot translate too much information at once. Regardless, patients should still be respected and given options in their daily lives. When offering decisions, keep it simple: oatmeal or toast for breakfast, black or gray shoes, bathing before or after dinner.
3. Consider resources to improve self-care.
Implement equipment to improve safety and assist the patient with accomplishing tasks. Handheld showerheads, grab bars, and benches can make bathing easier and safer. A stairlift, toilet risers, and riser-recliner chairs can help the patient with mobility. Eating equipment such as non-spill cups or easy-grip cutlery can improve eating habits.
4. Make dressing easier.
If a patient struggles with choosing appropriate attire or can’t decide between clothing options, but still maintains the motor function to dress themselves, a caregiver can lay out clothing. Increase the ease of dressing by only using clothing that doesn’t have buttons or zippers. Swap out shoes with laces for Velcro or slip-on shoes.
5. Use signage around the house.
Labels, post-it notes, whiteboards, clocks, and timers can be used anywhere they are needed. These serve as reminders and can help with memory recall. Leaving a note on the bathroom mirror such as “brush your teeth” or setting an alarm when it’s time to take medication are simple additions to improve self-care.
References and Sources
- Alzheimer’s Association. (n.d.). Dementia vs. Alzheimer’s Disease: What Is the Difference? | alz.org. Alzheimer’s Association. Retrieved January 20, 2022, from https://www.alz.org/alzheimers-dementia/difference-between-dementia-and-alzheimer-s
- Alzheimer’s Disease: Stages, Symptoms & What to Expect. (2019, March 18). Cleveland Clinic. Retrieved January 20, 2022, from https://my.clevelandclinic.org/health/articles/11825-stages-of-alzheimers-disease
- Alzheimer Society of Manitoba. (2014). Reducing risk for falls for people with dementia. Alzheimer Society of Manitoba. Retrieved January 20, 2022, from https://www.alzheimer.mb.ca/wp-content/uploads/2013/09/2014-Dementia-Fall-Risk-Checklist-template.pdf
- Alzheimer’s Society. (n.d.). What equipment can improve the home of a person with dementia? Alzheimer’s Society. Retrieved January 20, 2022, from https://www.alzheimers.org.uk/get-support/staying-independent/what-equipment-improve-adapt-home-person-dementia
- Fernando, E., Fraser, M., Hendriksen, J., Kim, C. H., & Muir-Hunter, S. W. (2017). Risk Factors Associated with Falls in Older Adults with Dementia: A Systematic Review. Physiotherapy Canada. Physiotherapie Canada, 69(2), 161–170. https://doi.org/10.3138/ptc.2016-14
- Gleason, C. E., Gangnon, R. E., Fischer, B. L., & Mahoney, J. E. (2009). Increased risk for falling associated with subtle cognitive impairment: secondary analysis of a randomized clinical trial. Dementia and geriatric cognitive disorders, 27(6), 557–563. https://doi.org/10.1159/000228257
- Graff-Radford, J. (2019, April 23). Sundowning: Late-day confusion. Mayo Clinic. Retrieved January 20, 2022, from https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/expert-answers/sundowning/faq-20058511
- Rosenzweig, A. (2020, July 11). Causes of Death in People With Alzheimer’s Disease. Verywell Health. Retrieved January 20, 2022, from https://www.verywellhealth.com/what-causes-death-in-people-with-alzheimers-disease-98215