Long-Term Care Survey Alert

Published on Tue Mar 16, 2004 PDF

Turn your thinking about cognitive impairment on its head with these 4 tips.

Ever wish someone would wave a magic wand to improve residents' cognitive impairments?
  
The right care plan can do just that, pulling your facility's incidence of cognitive impairment quality indicator right own the flagpole.

Start by keeping an open mind about the potential causes of a resident's dementia, some of which may even be reversible if caught in time. "It's important to look for treatable conditions that can be causing the person's dementia, such as B-12 deficiency, thyroid conditions, HIV or syphilis," emphasizes Claudia Kawas, MD, an Alzheimer's disease expert and neurologist from Johns Hopkins Medical Institutions in Baltimore.

Consider This: "Residents with dementia, a gait disorder that looks like Parkinson's, and bladder control problems might just have a treatable condition called "normal pressure hydrocephalus," says Kawas. If so, the person may need a CT scan to look for enlarged ventricles. 

For personal stories of people with this condition whose symptoms reversed with treatment, go to www.allaboutnph.com/content/Oriana.htm. Also, the Hydrocephalus Association has resources on normal pressure hydrocephalus that you can order at www.hydroassoc.org/resources/resources.htm.

Even though some causes of dementia can be reversed, health care practitioners don't typically look into the cause of cognitive impairment, says Claire Hoffman, MS, RNC, CDDN, CLNC, principal of Hoffman & Associates in Royersford, PA. That's where a good nursing assessment at admission can identify gaps in a resident's initial work-up that led to a diagnosis of dementia. "Nursing assessment upon admission should involve data collection, including hospital information, physician notes, a review of the diagnostic testing, etc., so the nursing can identify what's missing," Hoffman counsels.

Rule Out Delirium

In addition, you want to rule out delirium in residents upon admission and in existing residents who show new signs of confusion or cognitive problems -- even if they have preexisting dementia. Use Section B of the MDS and the delirium RAP to differentiate between acute causes of delirium -- a life threatening condition -- and dementia. "A sudden increase in confusion warrants a careful evaluation for UTI, pneumonia or another acute condition," Kawas advises.

Check the Meds

Medications can cause delirium or longer standing cognitive problems. "As a general rule, a medication that the patient has taken without problems for a decade won't suddenly start causing cognitive changes, although there may be exceptions," says Kawas. But be suspicious of any new medication associated with a cognitive change. "Common culprits include psychoactive drugs (antidepressants, especially tricyclics in the elderly, pain medications, sleeping pills and anti-anxiety agents) and some blood pressure medications," Kawas cautions.

4 More Smart Moves

Consider these four other strategies to help improve residents' cognitive functioning:

1. Identify and address medical conditions that are making the dementia worse than it needs to be. "For example, one out of three people with dementia may have significant depression that's making them more confused or affecting their attention span," Kawas reports. "And depression responds to treatment," she emphasizes. In addition, a significant number of dementia patients may have anemia, renal failure, an infection, or a hearing/visual impairment that's also making their cognitive status appear worse than it really is, Kawas notes. One study showed that chronic anemia can actually cause cognitive decline over time.

2.  Look for environmental factors exacerbating residents' confusion. "The same things that cause everyone to feel disoriented and confused will cause the same in spades for a person with dementia," cautions Kawas. "That includes sleep deprivation, over stimulation and too much change."

3.  Don't overlook what Alzheimer's medications can do for a resident's functional status. For example, adding the new AD drug memantine to donepezil (Aricept) for patients with moderate to severe Alzheimer's resulted in significantly better outcomes than placebo on measures of cognition, activities of daily living and behavior, according to a recent study reported in the Journal of the American Medical Association.

"How long the physician continues to prescribe AD medications for a resident should be an individualized decision made by the patient's family, nursing home staff and the physician," says Ronald Petersen, PhD, MD, director of the Alzheimer's Disease Center at the Mayo Clinic in Rochester, NY. "But the resident and his family should be given the option of these medications," he tells Eli.

4.  Keep all residents as fit as possible with physical and mental exercises. The old adage, "use it or lose it," is really true, suggests Mary Lucero, NHA, president of Geriatric Resources Inc. in Radium Springs, NM.

Provide fun physical activities that energize residents, which can promote socialization and prevent or even reverse mild depression. Individualize favorite activities, such as crossword puzzles and Bingo, to residents' cognitive and physical abilities. "Also offer activities that involve seniors in problem-solving issues where they call on their life-time wisdom and skills," Lucero suggests. Another option is staging "moral plays" in which people talk about the times they encountered a certain moral dilemma and how they handled it.

You can also devise activities that help cognitively impaired residents tap into their long-term memories and rote learning abilities. For example, one Vermont facility has staff help residents with dementia memorize best-loved American poems with a lot of repetitive stanzas, Lucero notes.  "Within a couple of weeks, even residents who could not communicate otherwise are repeating poetry and old proverbs in an activity that taps into their automatic rote verbal skills," Lucero reports.