CHAPTER 31 Cognitive Disorders 331

As the disease progresses, the patient usually no longer nds interest in previous pleasurable activities. The lack of men-tal stimulation further contributes to cognitive decline. Box 31-1 outlines what is referred to as the four A s of Alzheimers disease.

One unusual problem associated with Alzheimers disease is misinterpreting the environment. Patients often have visual hallucinations of dead relatives. One patient was found to be routinely preparing meals for visiting family members, all of whom were actually deceased. The voices or sounds typically go along with the visual hallucinationsfor example, the perceived deceased relative is speaking to the patient. Olfac-tory, tactile, and gustatory hallucinations are the least com-mon types of hallucinations.

Delusions are common. These are misconceptions that have no basis in reality and are often accusatory. Delusions held by patients with Alzheimers disease are very different from ones held by patients with psychoses related to chronic

mental illnesses (e.g. schizophrenia). Delusions from the lat-ter are typically bizarre and often frightening. Patients with Alzheimers disease have delusions that are based somewhat on reality and are not usually fantastical. Common delusions that patients with Alzheimers disease may include the fol-lowing: Thinking that a deceased relative is alive (perhaps the most

common). Pathologic jealousy about the spouse having an extramarital

affair. Stealing something odd like the mortgage papers out of a safe

while leaving money. The nurse will need to nd out if any of these ideas are

factual. The patients 85-year-old wife may be going out on the town, and the patients mother may still be alive.

Illusions are almost universal and represent a worsening of the disease. An illusion is a misinterpretation of something that really does exist. Thinking ones image in a mirror is an intruder or trying to give ice cream to a doll mean that the patient really sees something other than a self-re ection or an inanimate object.

Somatic preoccupations blended with either or both aphasia(s) produce complaints that may not make sense. Patients may say my stomach hurts regardless of the ques-tion. Frequent somatic complaints often result in lots of diag-nostic testing without clear-cut results.

Misidenti cation is an example of calling a family mem-ber or a friend by another persons name. Family members are often devastated when the patient cannot remember their names. The nurse can educate the family about misidenti ca-tion and dispel any idea that it may be a humorous attempt by the patient.

Sundowning describes the period, usually in the afternoon and early evening, during which a patient becomes increas-ingly agitated and less redirectable ( Bellenir, 2008 ). The very word describes when this behavior classically occurs; how-ever, some patients have problems at other times of the day. No de nitive cause has been found for sundowning .

Loss of the ability to care for oneself is dif cult for all par-ties. Over time, the patient forgets how to take care of all personal care needs. Incontinence of bowel and/or bladder and wandering can become unmanageable behaviors. Once the behavioral and functional decline reaches this point, the patient usually requires 24-hour care. Incontinence and/or wandering often mean that the patient can no longer be cared for in the home.

Clinical Example: Patient with Alzheimers Disease Mrs. Jackson, a 72-year-old woman, has had dif culty recalling the names of people in her church for many years. Now she is having dif- culty understanding jokes because she has diminished abstract abili-ties. Mrs. Jackson has a type of expressive aphasia called word- nding dif culty. She described the choir as those people who sing at church. Recently she had a kitchen re after she turned on her stove not real-izing that she had put her purse in it the day before. Mrs. Jackson has Alzheimers disease.

Agnosia: Impaired ability to recognize or identify familiar objects and people in the absence of a visual or hearing impairment. Assess and adapt for visual impairment. Do not expect the patient to remember you; introduce yourself. Cover mirrors or pictures if they cause distress. Name objects and demonstrate their use. Keep area free of ingestible hazards (toiletries, chemical cleaning sup-

plies, checkers, buttons, unmonitored medicine). Aphasia: Language disturbances are exhibited in both expressing and understanding spoken words. Expressive aphasia is the inability to express thoughts in words; receptive aphasia is the inability to understand what is said. Assess and adapt for hearing loss. Observe and use gestures, tone, and facial expressions. Provide help with word nding. Restate your understanding of behaviors and word fragments. Acknowledge feelings expressed verbally and nonverbally. Use simple words and phrases; be concise and organized. Allow time for response. Listen carefully and encourage with nonverbal praise. Use pictures, symbols, and signs. Amnesia: Inability to learn new information or to recall previously learned information. Do not expect the patient to remember you; introduce yourself. Do not test the patients memory unnecessarily. Operate in the here and now. Provide orientation cues. Remember, you must adapt when the patient cannot change. Compensate for patients lost judgment or reasoning. Apraxia: Inability to carry out motor activities despite intact motor func-tion. Assess and adapt for motor weakness and swallowing dif culties. Simplify tasks; give step-by-step instructions and time for response. Initiate motion for patient with gentle guidance or touch.

BOX 31-1 FOUR A s OF ALZHEIMERS DISEASE* AND ADAPTIVE ACTIONS

*May also be present in other cognitive disorders.