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Geriatric giants
Musso and Nuñez (2006) described three entities known as geriatric giants:
• Confusional syndrome
• Incontinence
• Gait disorders.
Some aspects of self-neglect clinically resemble these geriatric giants. These geriatric giants can appear as an acute event or as an exacerbation of an already existing state, often being the only clinical expression of various diseases such as pneumonia, urinary infection, cardiac infarction, etc. Possession of any combination of any two of these can be life-threatening for the older person, as one illness can impact or exacerbate the other.
■ CONFUSIONAL SYNDROME
Normal ageing processes may affect memory by changing the way in which the brain stores information and by making it harder to recall stored information. In addition, some age-related memory illnesses are categorised as confusional syndromes.
Dementia
Dementia refers to a group of cognitive illnesses characterised by a gradual and progressive impairment in memory, intellect, judgement, language and insight and a deterioration in social skills. Dementia is a condition in which there is a gradual loss of brain function; it is a decline in cognitive/intellectual functioning. The main symptoms are usually loss of memory, confusion, problems with speech and understanding, changes in personality and behaviour, and an increased reliance on others for the activities of daily living (Royal College of Psychiatrists).
The most common form of dementia in older people is vascular dementia, which tends to occur secondary to cardiac problems. Vascular dementia refers to a subtle, progressive decline in memory and cognitive functioning. It occurs when the blood supply carrying oxygen and nutrients to the brain is interrupted by a blocked or diseased vascular system. If blood supply is blocked for longer than a few seconds, brain cells can die, causing damage to the cortex of the brain (the area associated with learning, memory and language). Table 4 outlines the differences between vascular dementia and Alzheimer’s disease.
Delirium
Delirium is an acute or sudden onset of mental confusion and rapid changes in brain function as a result of medical, social and/or environmental conditions. Signs of delirium include:
• Changes in cognitive function, e.g. worsened concentration, slow responses, confusion.
• Changes in perception, e.g. visual or auditory hallucinations.
Table 4 Key differences between Alzheimer’s and dementia
SIGNS AND SYMPTOMS | VASCULAR DEMENTIA | ALZHEIMER’S DISEASE |
Onset | Sudden | Gradual |
Course | Stepwise progression, fluctuating | Gradual steady decline |
Focal neurological changes | Present from outset | Develop in later stages |
Memory loss | Milder, patchy, difficulty retrieving information | First sign, gradual loss of memory |
Gait disorders | Early sign | Middle to late stages |
Incontinence | Early sign | Middle to late stages |
Personality | Remains intact longer | Gradual erosion |
Emotional ability | More emotionally labile | Less emotionally labile |
Depression | Common | Less common |
Hallucinations and delusions | Common | Sometimes present, especially in later stages |
Epileptic seizures | Seizures more likely at any stage | Seizures in later stages |
Vascular risk and risk of sudden death | High risk of stroke, even unexpected death | Lower risk of sudden death |
• Changes in physical function, e.g. reduced mobility, reduced movement, restlessness, agitation.
• Changes in appetite, and sleep disturbance.
• Changes in social behaviour, e.g. lack of cooperation with reasonable requests, withdrawal, or alterations in communication, mood and/or attitude.
Cognitive impairment
Cognitive impairment is a cognitive decline greater than expected for an individual’s age and educational level. Cognition is the mental acquisition of knowledge through thought, experience and the senses.
Mental capacity is often determined by healthcare professionals through use of the Mini-Mental State Examination (MMSE), Figure 3. Folstein et al. (see p. 56) (1975) developed the Mini-Mental State Examination and stated that it is a brief neuropsychological test for evaluating cognitive status. MMSE scores are affected by age and education level, with lower scores being associated with increasing age and lower educational level. According to Dufouil et al. (2000), the norm for an 85-year-old man is 26 out of 30.
Care
When an older person suffers from a confusional syndrome, the nurse must aim to provide care which is person-centred: respecting the individuality of the person, their unique personality and their life experiences that influence their response to the disease.
The nurse must value the importance of the perspective of the person with dementia and the importance of their relationships and interactions with others.
Orientation to Time
“What is the date?”
Registration
“Listen carefully. I am going to say three words. You say them back after I stop.
Ready? Here they are …
APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words back to me.” [Repeat up to 5 times, but score only the first trial.]
Naming
“What is this?” [Poi...
