Chapter 038

Chapter 38
Disorientation, Delirium,
and Dementia
Copyright © 2022 Elsevier, Inc. All Rights Reserved. 1

Age-Related Brain Changes
 Changes in the brain and nervous system
occur with aging.
 Confusion, delirium, and dementia cause cognitive
impairment but are NOT normal parts of aging.
 Certain diseases can cause changes in the
brain.
 See Box 38.1: A Comparison of Normal and
Abnormal Nervous System Changes (p. 893)

Disorientation (1 of 6)
 Also called confusion.
 Refers to an impaired ability to recall people,
time or places.
 In most cases, there is an underlying medical
condition (e.g., depression, brain tumour,
electrolyte imbalance) causing the
disorientation.

 Disorientation can occur suddenly or
gradually over a long period of time.
 It is more common in older people.
 Sometimes it is reversible.
 Whether or not it is reversible depends on the
cause.

 Signs and symptoms of disorientation:
 People often exhibit behaviour changes and may
be angry, restless, depressed, or irritable.
 Other symptoms:
• Anxiety
• Tremors
• Hallucinations
• Delusions
• Decline in level of consciousness (LOC)
• Disorganized thinking and speech
• Attention problems

 Causes of disorientation:
 Urinary tract infections (UTIs)—one of the main
causes
 Alcohol intoxication
 Low blood sugar
 Head trauma and injury; concussion
 Nutritional deficiencies
 Fever

 Causes of disorientation:
 Medications
 Sleep deprivation
 Seizures
 Certain physiological illness especially, in older
persons
 Others

 Ways to minimize or prevent disorientation:
 Get regular hours of sleep.
 Eat a balanced diet that has plenty of vitamins and minerals.
 Do not drink alcohol in excess.
 Maintain careful control of blood sugar if diabetes is present.
 Don’t smoke.
 Sudden onset of disorientation without a known
cause requires immediate medical attention within
hours, or it could result in permanent cognitive,
mental, or physical disorders, or even death.

Slide 8
Delirium (1 of 5)
 Disorientation that occurs suddenly.
 A state of temporary, but acute, mental
confusion.
 Onset is sudden.
• It is common in older persons with acute or chronic
illnesses.
 Delirium is an emergency.
• The cause must be found and treated immediately before
symptoms become permanent.

Delirium (2 of 5)
 Common causes include:
 Reaction to medications
 Infection or other illnesses
 Poor nutrition
 Food poisoning
 Dehydration
 Emotional trauma
 Major life changes (e.g., death of a loved one)

Delirium (3 of 5)
 Signs and symptoms of delirium:
 Attention disturbances, difficulty concentrating
 Incoherent speech
 Disorientation to time or place
 Changes in sensation and perception
 Signs of illusions and hallucinations

Delirium (4 of 5)
 Signs and symptoms of delirium:
 Altered level consciousness or awareness
 Altered sleep patterns; drowsiness
 Level of alertness may vary
 Decrease in short-term memory and recall
 Changes in motor activities, movement
 Emotional or personality changes

Delirium (5 of 5)
 Diagnosis and treatment of delirium
 Blood work
 EEG, CT or MRI, chest X-ray, or spinal tap
 The goal of treatment is to control or reverse
cause of symptoms, and may include:
• Stopping medications
• Successful early treatment for coexisting disorders will
improve mental functioning.
• Sometimes medications are given
• Some people are admitted to a psychiatric facility
 See textbook box: Supporting Mrs. Thomas, Part 2:
Recognizing Delirium and Acting Quickly
Dementia (1 of 19)
 Dementia is the progressive loss of cognitive
and social functions – it is not a normal part
of aging.
 It interferes with routine personal, social, and
occupational activities.
 It affects the ability to perform simple tasks (e.g.,
bathing, dressing, eating) and complex tasks (e.g.,
driving, managing money, planning meals,
working).
 Dementia is a group of symptoms that may
occur with certain diseases or conditions.

Dementia (2 of 19)
 Dementia is more common after 65 years of
age but can also affect people in their 40s
and 50s.
 When diagnosed, it is either categorized as a mild
or major neurocognitive disorder.
 Categorization is based on decline in attention,
function, learning, memory, language, deliberate
motor movement, and social functioning.

Dementia (3 of 19)
 See tables:
 Textbook Table 38.1: Typical Symptoms and
Support Strategies for Early Stage of Dementia
Support Strategies for Middle Stage of Dementia
Support Strategies for Late Stage of Dementia

Dementia (4 of 19)
 Some early warning signs include:
 Recent memory loss that affects job skills
 Problems with common tasks
 Problems with language; forgetting simple words
 Getting lost in familiar places
 Misplacing things and putting things in odd places
 Personality changes
 Poor or decreased judgement
 Loss of interest in life

Dementia (5 of 19)
 Untreatable (irreversible) forms of dementia:
 Also known as primary dementia.
 Brain function will decline over time.
 Types include:
• Alzheimer’s disease (AD)
• Vascular dementia
• Dementia with Lewy bodies
• Frontotemporal dementia

Dementia (6 of 19)
 Treatable (reversible) forms of dementia:
 Also known as secondary dementia.
 If changes in the brain have not occurred, some
dementias can be reversed.
 Treatable forms of dementia include:
• Metabolic issues
• Brain injury
• Brain tumour
• Substance abuse
• Nutritional deficiencies
• Infections
• Poisoning
Dementia (7 of 19)
 Alzheimer’s disease and related dementias
(ADRD):
 Account for over 64% of dementias in Canadians
 Are the most common form of dementia
 Not all those diagnosed with dementia will have ADRD.

Slide 20
Dementia (8 of 19)
(ADRD):
 A primary disorder of the brain
 Categorized as either a major or minor
neurocognitive disorder.
 First identified by Dr. Alois Alzheimer in 1906.
 Has two distinguishing characteristics:
• Plaques: deposits in brain that become toxic
• Tangles: interfere with vital processes

Dementia (9 of 19)
(ADRD):
 The brain physically shrinks.
 Involves loss of connectivity (ability of one cell to
communicate with another)—leads to symptoms of
Alzheimer’s.
 Usually occurs after age 65, and is often
diagnosed after age 80.
• Can also affect people in their 40s and 50s.
 No cure, but some medications can slow progress.
• Span of cognitive decline is 3-20 years (average is 8-12
years)
Dementia (10 of 19)
 Warning signs of ADRD (according to
Alzheimer’s Society of Canada):
 Memory loss affecting day-to-day abilities
 Difficulty performing familiar tasks
 Difficulties with language
 Disorientation in time and space
 Impaired judgement
 Problems with abstract thinking

Dementia (11 of 19)
 Warning signs of ADRD (according to
Alzheimer’s Society of Canada):
 Misplacing things
 Changes in mood and behaviour
 Changes in personality
 Loss of initiative

Dementia (12 of 19)
 Vascular dementia (multi-infarct dementia)
 One of the most common types of dementia,
second to Alzheimer’s disease.
 Caused by small strokes resulting in brain tissue
death.
• The cortex of the brain is associated with learning,
memory, and language.
• These strokes do not necessarily lead to hemiplegia but
may instead cause changes in personality or memory.
• These strokes are known as “silent strokes” or transient
ischemic attacks (TIAs)

Dementia (13 of 19)
 Vascular dementia (multi-infarct dementia):
 Behavioural or physical symptoms can come on
gradually or suddenly.
 There is no cure.
 Disease progresses in a stepwise fashion:
• Starts with lapses in memory, followed by periods of
stability, then further decline.

Dementia Dementia (14 of 19)
 Common mental and emotional signs and
symptoms of vascular dementia include:
 Slowed thinking
 Memory impairment
 Unusual mood changes (e.g., irritability,
depression)
 Hallucinations and delusions
 Disorientation, may get worse at night
(sundowning)
 Personality changes and loss of social skills

Dementia (15 of 19)
 Dementia with Lewy bodies (DLB):
 One of the most common types of progressive
dementia.
 Involves progressive decline combined with three
additional defining features:
• Severe fluctuations in alertness and attention
• Recurrent visual hallucinations
• Parkinson-like motor symptoms

Dementia (16 of 19)
 Dementia with Lewy bodies (DLB) (cont.):
 People with DLB may also suffer from depression:
• Symptoms are caused by build-up of Lewy bodies
• Accumulated bits of protein in area of the brain
regulating aspects of memory and motor control
 There is no known familial connection, but there
are some rare cases.

Dementia (17 of 19)
 Frontotemporal degeneration dementia (FTD)
 A rare form of dementia (only 5% of all dementias
are this type)
 Affects the frontal and temporal lobes of the brain
 Occurs between 40-60 years of age
• Women are more affected than men
 Characterized by dramatic changes in personality,
behaviour, and thought process:
• Loss of inhibition
• Apathy
• Social withdrawal
• Mouthing objects
• Ritualistic compulsive behaviours
Dementia (18 of 19)
 Early symptoms of FTD
 Social and emotional functions are impacted first.
• Mood changes (leaning towards euphoria)
• Lack of inhibitions—altered sexual behaviour
• Deterioration in social skills, rude, impatient
• Extroverted or withdrawn
• Aggressive, makes inappropriate remarks
• Difficulty maintaining a line of thought, easily distracted,
difficulty maintaining conversation

Dementia (19 of 19)
 Types of FTD:
 Pick’s disease
• Marked by presence of abnormalities in brain cells
(Pick’s bodies)
• Behavioural changes are very subtle at first.
• Dementia is recognized when behaviour becomes more
bizarre.
 Mixed dementia
• Has characteristics of both Alzheimer’s disease and
vascular dementia
• Now believed to be more common than previously
thought.

Secondary Dementias (1 of 9)
 Dementia that results from the physical
effects of a disease process (e.g., ingestion of
damaging substance or from injury)
 Types include the following:
 Parkinson’s disease dementia
 Creutzfeldt-Jakob disease
 Normal-pressure hydrocephalus
 Substance-induced persisting dementias
 Wernicke-Korsakoff syndrome

Slide 33
 Parkinson’s Disease Dementia
 Parkinson’s disease affects the brain’s ability to
control movement.
 Involves tremors, stiffness, slowness, difficulty walking,
loss of balance
 In later stage of the disease, some people may also
develop dementia.
 May also develop depression

Slide 34
 Creutzfeldt-Jakob Disease (CJD)
 A very rare disease that causes dementia
 A rapid progressive neurological disease—it is
rapidly fatal.
 There is a genetic link or susceptibility.
 Occurs between ages of 50-70 years.
 Affects both people and animals.

 Creutzfeldt-Jakob Disease (CJD)
 Signs include:
• Fatigue
• Difficulty sleeping and insomnia, excessive sleepiness
• Changes in personality
• Balance and walking disturbances

 Normal-Pressure Hydrocephalus:
 People with a history of brain hemorrhage or
meningitis are at increased risk for this type of
dementia.
 Symptoms:
• Difficulty walking
• Memory loss
• Inability to control urination
 Can sometimes be corrected with a shunt in the
brain.

 Substance-Induced Persisting Dementias
 Result from persisting effects of an abused
substance, medication, toxic substance exposure,
or alcohol.
 Caused by:
 Toxic effects of the substance on brain cells
 Substance-related effects on internal organs
 Acquired brain injuries (ABI) related to falls sustained
while impaired or disoriented
• Remember DIPPS principles and act
professionally when providing care to clients.

Slide 38
 Wernicke-Korsakoff Syndrome (WKS):
 A brain disorder caused by lack of thiamine
(vitamin B)
 Associated with alcohol use disorder over a long
period of time:
• Many heavy drinkers have severe malnutrition, poor
eating habits.
• Alcohol can inflame stomach lining and impede body’s
ability to absorb the key vitamins it receives.

 Wernicke-Korsakoff Syndrome (WKS):
 Causes the following:
• Impairment to memory and intellectual or cognitive skills
• Symptoms of nerve damage
• Most distinguishing symptom is confabulation
(fabrication)
 Treatment
• Involves thiamine replacement therapy
• Proper nutrition and hydration

 Other Causes of Secondary Dementias

 Acquired immune deficiency syndrome
 Huntington’s disease
 Multiple sclerosis (MS)
 Syphilis

Slide 41
Depression and Dementia
(1 of 6)
 The causes of major depression and
dementia may be totally unrelated.
 Sometimes depression in some clients can be
mistaken for dementia.
 Depression is sometimes called pseudo-dementia.
 People showing signs of early ADRD might be
mistaken as being depressed.

(2 of 6)
 Symptoms common to both depression and
dementia include the following:
 Lack of concern for surroundings
 Loss of interest in activities and hobbies
 Social withdrawal and isolation
 Trouble concentrating
 Impaired thinking
 It is estimated that up to 40% of people with

ADRD also have a major depressive disorder.
Slide 43
(3 of 6)
 People with dementia are less likely to tell
others of their feelings associated with
depression.
 It is difficult to diagnose depression in clients with
ADRD.
 Symptoms of depression differ between people
who have depression and ADRD and those
without ADRD
• Symptoms may not last as long for people with ADRD
• Symptoms may come go in people with ADRD

(4 of 6)
 People with ADRD may be less likely to talk about
or attempt suicide
 Proper diagnosis and treatment is important
 Treatment:
• Involves a combination medication, counselling, and
encouraged socialization and activities

(5 of 6)
 Supporting a Client Living with Dementia Who
is Depressed
 Support groups are helpful and should be
encouraged.
 Schedule predictable routines, high-energy
activities (e.g., bathing during client’s best time of
the day).
 Frequently schedule activities, food, people or
places that client enjoys.

(6 of 6)
 Supporting a Client Living with Dementia Who
is Depressed:
 Assist client with regular exercises.
 Validate clients’ feelings of sadness and
frustration.
 Celebrate small successes.
 Reassure client that they are loved, respected,
and appreciated.
 Reassure the client that they will not be
abandoned.

Stages of Dementia (1 of 5)
 Staging systems:
 Most dementias are classified using these 3
stages:
• (1) early stage
• (2) middle stage
• (3) late stage
 Another staging system is the Global Deterioration
Scale (Reisberg Scale)
• Divides the disease process into 7 stages

 Staging (cont):
 Dementia affects each client differently, depending
on which part of the brain is affected.
 The length of each stage varies.
 Stages will overlap.
 Some clients will experience several symptoms,
others only a few symptoms.

 Stage 1: Mild (early stage)
 Client is usually aware of diagnosis and will be
able to participate in decisions affecting future
care.
 Experiences mild forgetfulness, difficulty learning
new things, problems with orientation,
communication difficulties.

 Stage 2: Moderate (middle stage)
 Further decline occurs in client’s mental and
physical abilities.
 Memory continues to deteriorate—client may
forget personal history; may not recognize friends
and family.
 Some clients become restless and pace constantly
or may wander off.
• Register such clients with MedicAlert Safely Home
program (which can assist with locating client if they
should become lost).

 Stage 3: Severe (late stage)
 Client is incapable of remembering,
communicating, or carrying out self-care.
 Care is required 24 hours a day.

Supporting Clients Who Are
Living With Dementia (1 of 2)
 Each client living with dementia has unique
care needs, depending on the form and stage
of dementia they have, and the care setting
they are in.
 See textbook box: Providing Compassionate Care:
The Client Living with Dementia

Supporting Clients Who Are
Living With Dementia (2 of 2)
 Guidelines for caring for clients include:
• Meeting basic needs
• Safety (protect from wandering, falls)
• Hygiene, grooming, and dressing
• Elimination needs
• Nutrition and fluids
• Exercise
• Health issues
• Comfort
• Sleep
• Therapy and activities

Managing Responsive
Behaviours (1 of 3)
 Responsive behaviours usually originate as
responses to an illness, infection, or physical
discomfort.
 All behaviour has meaning—the client is
responding to something in their internal or
external environment
 Caregivers must try to understand the behaviours.
• Clients living with dementia cannot control their actions,
so never take their behaviours personally.
 Follow DIPPS
• See textbook box: Think About Safety: The ABCDs of
Managing Responsive Behaviours
Managing Responsive
Behaviours (2 of 3)
 Common responsive behaviours exhibited by
clients:
 Wandering
 Sundowning (signs, symptoms, and behaviors of
AD increase during hours of darkness)
 Hallucinations (seeing, hearing, smelling, or
feeling something that is not real)
 Delusions (false beliefs)
 Catastrophic reactions (extreme responses)

Managing Responsive
Behaviours (3 of 3)
 Common responsive behaviours exhibited by
clients (cont.):
 Agitation and restlessness
 Aggression and combativeness
 Screaming
 Sexual behaviours
 Repetitive behaviours
 Hoarding

Validation Therapy
 Focuses on empathy and advocates
accepting the affected person’s perception of
reality.
 The purpose is to make client feel supported and
respected.
 Caregiver focuses on descriptive clues that
the client provides
 See textbook Box 38.3: Principles of Validation Therapy
 See textbook box: Supporting Mrs. Yi: Using Validation
Therapy

Slide 58
Gentle Persuasive Approaches
 Gentle Persuasive Approaches (GPA) is a
program initially designed for use by long-
term care home staff.
 Teaches workers to be self-protective, respectful,
and nonviolent and to prevent workplace injury.
 Designed to train direct care providers on how
best respond to clients with responsive behaviours
(e.g., grabbing, hitting, biting) that are associated
with Alzheimer’s disease.

Slide 59
Caregiver Needs (1 of 4)
 The family
 Health care is sought when the family has difficulty
dealing with the situation or meeting the client’s
needs.
• Home health care may help for a while.
• Adult day care is an option.
• Long-term care is needed when:
 Family members cannot meet the client’s needs.
 The client no longer knows the caregiver.
 Family members have health problems.
 Money problems occur.
 The client’s behaviour presents dangers to self and
others.
 The family:
 The client’s medical care can drain family
finances.
 The family has special needs.
 Adult children are in the sandwich generation
• They are caught between their own children who need attention
and an ill parent who needs care.

 The family:
 Caregivers
need much support and
encouragement.
• Many join support groups sponsored by Alzheimer’s Society of
Canada, hospitals. or long-term care facilities.
 The family often feels helpless, guilty
 The family is an important part of the health team.
• They need support and understanding from the health team.

 Caregiver Relief:
 As a support worker, you may assist the primary
caregiver, or care for the client and provide respite
for the caregiver.
 Follow the care plan.
 Observe signs of caregiver stress and signs of
depression and abuse.
 Report all observations immediately to your
supervisor
• See textbook box: Case Study: Supporting Caregivers of Clients Living
with Dementia

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Chapter 38

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 Other Causes of Secondary Dementias

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 Loss of interest in activities and hobbies

 Social withdrawal and isolation

 It is estimated that up to 40% of people with

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