526 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERSJudgmentbegin to demonstrate catastrophic emotional reactions
in response to environmental changes that clients
may not perceive or understand accurately or when
they cannot respond adaptively. These catastrophic
reactions may include verbal or physical aggression,
wandering at night, agitation, or other behaviors that
seem to indicate a loss of personal control.
Clients may display a pattern of withdrawal
from the world they no longer understand. They are
lethargic, look apathetic, and pay little attention to
the environment or the people in it. They appear to
lose all emotional affect and seem dazed and listless.THOUGHT PROCESS AND CONTENT
Initially the ability to think abstractly is impaired,
resulting in loss of the ability to plan, sequence, mon-
itor, initiate, or stop complex behavior (APA, 2000).
The client loses the ability to solve problems or to
take action in new situations because he or she can-
not think about what to do. The ability to generalize
knowledge from one situation to another is lost be-
cause the client cannot recognize similarities or dif-
ferences in situations. These problems with cognition
make it impossible for the employed client to con-
tinue working. The client’s ability to perform tasks
such as planning activities, budgeting, or planning
meals is lost.
As the dementia progresses, delusions of perse-
cution are common. The client may accuse others of
stealing objects he or she has lost or may believe he
or she is being cheated or pursued.SENSORIUM AND
INTELLECTUAL PROCESSES
Clients lose intellectual function, which eventually
involves the complete loss of their abilities. Memory
deficits are the initial and essential feature of de-
mentia. Dementia first affects recent and immediate
memory, then eventually impairs the ability to rec-
ognize close family members and even oneself. In mild
and moderate dementia, clients may make up answers
to fill in memory gaps (confabulation). Agnosia is
another hallmark of dementia. Clients lose visual spa-
tial relations, which is often evidenced by deteriora-
tion of the ability to write or draw simple objects.
Attention span and ability to concentrate are in-
creasingly impaired until clients lose the ability to do
either. Clients are chronically confused about the en-
vironment, other people, and eventually themselves.
Initially they are disoriented to time in mild demen-
tia, time and place in moderate dementia, and finally
to self in the severe stage.
Hallucinations are a frequent problem. Visual
hallucinations are most common and generally un-
pleasant. Clients are likely to believe the hallucina-
tion is reality.JUDGMENT AND INSIGHT
Clients with dementia have poor judgment in light of
the cognitive impairment. They underestimate risks
and unrealistically appraise their abilities, which re-
sults in a high risk for injury. Clients cannot evalu-
ate situations for risks or danger. For example, they
may wander outside in the winter wearing only thin
nightclothes and not consider this to be a risk.
Insight is limited. Initially the client may be
aware of problems with memory and cognition and
may worry that he or she is “losing my mind.” Quite
quickly, these concerns over the ability to function
diminish, and clients have little or no awareness of
the more serious deficits that have developed. In this
context, clients may accuse others of stealing posses-
sions that have actually been lost or forgotten.SELF-CONCEPT
Initially clients may be angry or frustrated with them-
selves for losing objects or forgetting important things.
Some clients express sadness at their bodies for get-
ting old and at the loss of functioning. Soon, though,