524 Unit 4 NURSINGPRACTICE FORPSYCHIATRICDISORDERS
- Parkinson’s diseaseis a slowly progres-
sive neurologic condition characterized by
tremor, rigidity, bradykinesia, and postural
instability. It results from loss of neurons
of the basal ganglia. Dementia has been
reported in approximately 20% to 60% of
people with Parkinson’s disease and is
characterized by cognitive and motor slow-
ing, impaired memory, and impaired execu-
tive functioning. - Huntington’s diseaseis an inherited,
dominant gene disease that primarily
involves cerebral atrophy, demyelination,
and enlargement of the brain ventricles.
Initially there are choreiform movements
that are continuous during waking hours
and involve facial contortions, twisting,
turning, and tongue movements. Personality
changes are the initial psychosocial manifes-
tations followed by memory loss, decreased
intellectual functioning, and other signs of
dementia. The disease begins in the late 30s
or early 40s and may last 10 to 20 years or
more before death. - Dementia can be a direct pathophysiologic
consequence of head trauma. The degree and
type of cognitive impairment and behavioral
disturbance depend on the location and
extent of the brain injury. When it occurs
as a single injury, the dementia is usually
stable rather than progressive. Repeated
head injury (for example, from boxing) may
lead to progressive dementia.
An estimated 5 million people in the United States
have moderate to severe dementia from various causes
(Alzheimer’s Association, 2002). Prevalence rises with
age. Estimated prevalence of moderate to severe de-
mentia in people older than 65 years is about 5%.
Dementia of the Alzheimer’s type is the most common
type in North America, Scandinavia, and Europe;
vascular dementia is more prevalent in Russia and
Japan. Dementia of the Alzheimer’s type is more com-
mon in women; vascular dementia is more common
in men.
Cultural Considerations
Clients from other cultures may find the questions
used on many assessment tools for dementia difficult
or impossible to answer. Examples include the names
of former U.S. presidents. To avoid drawing erroneous
conclusions, the nurse must be aware of differences
in the person’s knowledge base.
The nurse also must be aware of different cul-
turally influenced perspectives and beliefs about
elderly family members. In many Eastern countries
and among Native Americans, elders hold a position
of authority, respect, power, and decision-making for
the family; this does not change despite memory loss
or confusion. For fear of seeming disrespectful, other
family members may be reluctant to make decisions
or plans for elders with dementia. The nurse must
work with family members to accomplish goals with-
out making them feel that they have betrayed the
revered elder.Treatment and Prognosis
Whenever possible, the underlying cause of demen-
tia is identified so that treatment can be instituted.
For example, the progress of vascular dementia, the
second most common type, may be halted with ap-
propriate treatment of the underlying vascular con-
dition (e.g., changes in diet, exercise, control of hyper-
tension or diabetes). Improvement of cerebral blood
flow may arrest the progress of vascular dementia in
some people (Caine & Lyness, 2000).
The prognosis for the progressive types of de-
mentia may vary as described above but all prognoses
involve progressive deterioration of physical and men-
tal abilities until death. Typically in the latter stages,
clients have minimal cognitive and motor function,
are totally dependent on caregivers, and are unaware
of their surroundings or people in the environment.
They may be totally uncommunicative or make un-
intelligible sounds or attempts to verbalize.
For degenerative dementias, no direct therapies
have been found to reverse or retard the fundamen-
tal pathophysiologic processes (Caine & Lyness, 2000).
Levels of numerous neurotransmitters, such as acetyl-
choline,dopamine, norepinephrine, and serotonin,
are decreased in dementia. This has led to attempts
at replenishment therapy with acetylcholine pre-
cursors, cholinergic agonists, and cholinesterase in-
hibitors. Tacrine (Cognex), donepezil (Aricept), rivas-
tigmine (Exelon), and galantamine (Reminyl) are
cholinesterase inhibitors and have shown modest
therapeutic effects and temporarily slow the progress
of dementia (Table 21-2). They have no effect, how-
ever, on the overall course of the disease. Tacrine ele-
vates liver enzymes in about 50% of clients using it;
therefore, liver function is assessed every 1 to 2 weeks.
Clients with dementia demonstrate a broad range
of behaviors that can be treated symptomatically.
Doses of medications are one-half to two-thirds lower
than usually prescribed (Caine & Lyness, 2000). Anti-
depressantsare effective for significant depressive
symptoms.Antipsychotics such as haloperidol (Hal-
dol), olanzapine (Zyprexa), risperidone (Risperdal),
and quetiapine (Seroquel) may be used to manage