This dementia patient can be helped
Republished with permission of Medical Economics Publishing Co., Inc. from 'RN' , Fraser, Cira, (v59 n1) Start Page: p38(5) ISSN: 0033-7021, Jan 1996; permission conveyed through Copyright Clearance Center, Inc.
Sal Romano, a 78-year-old with type II diabetes, lives alone, but his family has been keeping very close tabs on him for about a year. According to his daughter, that's when he started to 'think more slowly' and become forgetful. He lost interest in his favorite pastimes, too - writing letters tothe editor of the local paper and participating in political campaigns. He also started walking differently - in very small, slow, unsteady steps as if his feet were glued to the floor.
In recent months, Mr. Romano has had trouble handling simple tasks. He needs help balancing his checkbook, for example, because he can no longer do the math. He's also started to behave oddly, at times using his car to move personal items from his house to a similar-looking one nearby.
These problems prompted Mr. Romano's daughter to take him to his primary care physician. Without ordering any diagnostic tests, the physician diagnosed senile dementia, and told her that nothing could be done to help him.
Since that visit, Mr. Romano's short-term memory, concentration, and dementia have continued to worsen. He frequently misplaces household items and then accuses others, usually his grandchildren, of taking them. He often gets lost in his own neighborhood. And he goes to sleep twice a day instead of just at night.
Falls are becoming a frequent problem for Mr. Romano because of his increasingly unsteady gait. He has developed occasional urinary incontinence. Fearing for his health and safety, his daughter made another appointment with the doctor - who again maintained that Mr. Romano has an untreatable dementia. Unwilling to accept that sentence, the daughter has brought Mr. Romano to the new geropsychiatric unit at the local hospital.
When fluid accumulates in the brain's ventricles
Once Mr. Romano is admitted, a team consisting of the attending physician, nurses, a psychiatrist, a neurologist, and a social worker begin trying to identify the cause of his dementia. This crucial step is one that many doctors in general practice omit, as did Mr. Romano's private physician.
That may be particularly true of physicians over age 40. Their medical education typically did not cover geriatrics,(1) so they're less likely to be familiar with dementia. In addition, the extensive media attention given to Alzheimer's disease, an irreversible form of dementia, has given clinicians and lay people alike the impression that all dementias are untreatable.
That's true most of the time, but it's not always the case. Among those who develop dementia - and a third of the 85-and-over population does(2) - such causes as drug toxicity, hypothyroidism, subdural hematoma, and depression are definitely treatable.(3) In Mr. Romano's case, a CT scan and lumbar puncture reveal a less common treatable cause of dementia - normal pressure hydrocephalus (NPH).
NPH is responsible for about 2% of all dementias,(4) and typically affects those over age 50.(5) With this condition, the ventricles in the brain become enlarged when cerebrospinal fluid builds up. Spinal CSF pressure typically remains normal, however.(5)
When the reason for the fluid accumulation can't be identified - and that's usually the case(4) - the patient is said to have idiopathic NPH. Individuals at high risk include those with hypertension, ischemic heart disease, an EKG indicative of ischemia, low levels of high-density lipoprotein (HDL) or 'good' cholesterol, and diabetes.
In the few cases in which the cause of NPH is known, subarachnoid hemorrhage, infections like meningitis, and head trauma are most often to blame. Researchers believe these conditions precipitate NPH by reducing the absorption of cerebrospinal fluid by the arachnoid villi - the web-like vasculature surrounding the brain's exterior.
Whatever the cause, cerebral compression from ventricle enlargement commonly produces three classic signs, all of which Mr. Romano displays: dementia, gait disturbance, and urinary incontinence.
Dementia is characterized by slight to moderate memory impairment related to the patient's decreased ability to concentrate, psychomotor retardation, decreased spontaneity - particularly when speaking - and loss of initiative and interest in his usual activities.
Gait disturbance is marked by a wide stance and short, slow, shuffling steps; the patient's feet are often described as being, 'glued to the floor.' Complaints of diffuse leg weakness and fatigue are common. NPH may also affect the upper extremities, causing motor disturbances of the hand make it difficult to write.
Urinary incontinence is usually the last sign of NPH to appear. Some patients, however, never develop it at all.
Treatment diverts CSF toward the abdomen
NPH isn't diagnosed based on signs and symptoms alone. The patient must undergo a CT scan or MRI - both of which reveal enlarged ventricle - and then a lumbar puncture, which typically shows normal CSF pressure, although it may be increased or decreased in some cases.
Although these procedures are sufficient to make a diagnosis, the physician may wish to confirm his findings with isotopic cisternography. This test, designed specifically to detect hydrocephalus, involves injecting a radioactive isotope into the subarachnoid space. It is followed by periodic scanning for up to 8 hours to evaluate the absorption of cerebrospinal fluid.
Within an hour of undergoing the lumbar puncture, which typically includes the removal of 40 - 50 ml of cerebrospinal fluid, Mr. Romano shows improvement, mainly in gait, that lasts almost a day. That' a positive sign, and it means there's a good chance he'll benefit from the standard intervention for NPH-insertion of a ventriculoperitoneal (VP) shunt to drain excess cerebrospinal fluid.
There's a lack of data on the success rate of this procedure, but what is available suggests that anywhere up to 80% of patients experience at least some improvement in cognition, gait, and continence that can begin as soon as two days postop and progresses for months. And although it's unclear why, studies suggest that improvement tends to be best in patients who developed gait disturbances before the onset of dementia.
Before Mr. Romano undergoes insertion of the VP shunt, a nurse provides routine preop teaching. Aware that Mr. Romano's dementia may make communicating difficult, she approaches him slowly and maintains direct eye contact. She speaks simply and directly - lowering the pitch of her voice and avoiding complex gesture - and occasionally touches his hand or shoulder to keep his attention.
The nurse asks Mr. Romano questions one at a time, and allows up to 20 seconds for a response. If she needs to repeat a question, she uses the same words to avoid confusing him. She supplements her teaching with written materials.
She makes sure all water pitchers, cups, and drinking glasses have been removed from the room, as well, since Mr. Romano must remain NPO. When helping to prepare him for transfer to the OR, she proceeds in an unhurried manner to minimize the likelihood that he win become anxious or aggressive.
The nurse also takes time to provide emotional support to Mr. Romano's daughter. That's essential because many family members of NPH patients are angry and frustrated over their loved one's condition and the fact that they'd been initially misinformed about the chances for recovery.
Once Mr. Romano is under general anesthesia, the shunt is placed in the lateral ventricle on the non-dominant side of the brain. That's the location of choice because it minimizes the likelihood of damage to the dominant side during surgery - although the risk of any damage is small to begin with.
When the surgery is complete, the shunt is working just as it should be. Cerebrospinal fluid is flowing into the collection catheter, which has a one-way valve that prevents backflow, and emptying into a small reservoir. The fluid then flows into an exit catheter, which is tunneled beneath the skin and leads to the peritoneal cavity.
Post-op care focuses on minimizing risks
Mr. Romano stays in the neurological ICU for the first 24 hours postop with a cranial dressing covering the incision on his head. There's a small dressing on his abdomen, too. It covers an incision made during catheter placement.
In some cases, the surgeon also makes an incision on the side of the neck during catheter placement. Those incisions are covered with a small dressing, as well. Every two hours for the first eight hours postop, and then once a shift, Mr. Romano's nurses monitor the cranial dressing for bleeding and drainage of cerebrospinal fluid. They assess both his incision sites for signs of infection like redness, drainage, and foul odor. They also review the neurosurgeon's instructions for positioning the head of the bed, and follow them closely. This is vital for preventing sudden drainage from the shunt, which can lead to cerebral hemorrhaging.
Orders commonly call for the head of the bed to remain flat for the first 24 hours, followed by gradual elevation progressing to 90 [degrees] after four days. The physician's instructions may also include placing the patient on Ids side - the one opposite the shunt - to avoid pressure to the cranial incision.(10)
Every 15 - 30 minutes for the first eight to 12 hours postop and then once an hour for the next 12 hours, the nurses do a neurological assessment to monitor for early signs of increased intracranial pressure and intracranial bleeding. These include headache, restlessness, reduced level of consciousness, sluggish pupillary response, and muscle weakness. Aware that epilepsy is a possible complication of VP shunt insertion,(7) albeit an unlikely one, Mr. Romano's nurses maintain seizure precautions. These include storing the equipment needed for giving oxygen at the bedside, taping an appropriate-sized airway over the head of the bed, and keeping the bed in a low position with the side rails up.
Since Mr. Romano's gait disturbance makes him vulnerable to falls' he's placed on a falls prevention program following transfer from the NICU to the med/surg floor. This includes a room assignment near the nurses station to facilitate frequent safety checks by the staff. His nurses also make sure personal items and the call-light are within easy reach.
To maintain muscle strength and endurance and thereby make falls less likely to occur, the nurses regularly assist Mr. Romano in performing range-of-motion exercises. When the physician says he's ready to get up, they make sure to walk him to the bathroom at least every two hours, providing a walker for stability when necessary.
Because Mr. Romano's attention span is reduced, he's at risk for accidental injury - for example, by inadvertently spilling a hot liquid on himself during mealtime. His nurses take precautions wherever possible, in this case removing hot liquids from the patient's meal tray until they cool.
After discharge, progress is gradual
A week after his surgery, Mr. Romano is ready for discharge, although he'll be back in a few days to have his sutures removed. Before he leaves, a nurse provides discharge teaching, making sure to include his daughter in the session since she'll be caring for him at home.
The nurse informs them that Mr. Romano will need physical therapy to minimize the risk of falling. She also suggests ways to prevent falls at home, such as wearing sturdy shoes, using a walker, maintaining clear pathways around the house, and, if possible, not leaving the patient unattended.
Infection at the incision sites is a possibility, so she teaches them the signs to watch for. She informs them, too, that while most VP shunts operate trouble-free for years, patients can experience complications. Malfunction is the most common, and may occur when tissue or exudate occlude the shunt, or the device becomes dislodged. This may lead to a relapse of NPH. Infection of the shunt itself is the next most common complication,(7) and often produces fever, weakness, lethargy, and irritability. The nurse instructs Mr. Romano and Ms daughter to report signs of shunt infection or any recurrence of NPH symptoms to the physician immediately.
A month after surgery, Mr. Romano is well on the road to recovery. His attention span is longer and he's better able to interact with others. Six months postop, his memory is better and he's again managing his finances and doing his own shopping. His gait is markedly improved and he can take long walks without getting lost. He no longer has problems with incontinence, as well. In a year, Mr. Romano is once again immersed in his favorite activities: writing letters to the editor and hitting the campaign trail.
Mr. Romano is particularly fortunate, however. Many family members accept a loved one's dementia without question when told that nothing can be done.' As nurses, we must educate family members, ourselves, and other caregivers - including physicians - about the need for a complete assessment in cases of dementia. If we do that, we're more likely to hear the words something can be done.'
[1.] Williams, M. E., & Connolly, N. L. (1990). What practicing physicians in North Carolina rate as their most challenging geriatric medicine concerns. JAGS, 38(11), 1230.
[2.] Ott, A., Breteler, N. M., et al. (1995). Prevalence of Alzheimer's disease and vascular dementia: Association with education. The Rotterdam study. BMJ, 310(6985), 970.
[3.] Pary, R., Tobia, C. R., & Lippmann, S. (1990). Dementia: What to do. South Med. J., 83(10), 1182.
[4.] Masters, J. C., & O'Grady, M. (1992). Normal pressure hydrocephalus: A potentially reversible form of dementia. J. Psychosoc. Nurs., 30(6), 25.
[5.] Barker, E. (1994). Neuroscience nursing. St. Louis: Mosby.
[6.] Casmiro, M., D'Alessandro, R., et al. (1989). Risk factors for the syndrome of ventricular enlargement with gait apraxia (idiopathic normal pressure hydrocephalus): A case-control study. Journal of Neurology, Neurosurgery, and Psychiatry, 52(7), 847.
[7.] Larsson, A., Wikkelso, C., et al. (1991). Clinical parameters in 74 consecutive patients shunt operated for normal pressure hydrocephalus. Acta. Neurol. Scand., 84(6), 475.
[8.] Turner, D. A., & McGeachie, R. E. (1988). Normal pressure hydrocephalus and dementia - valuation and treatment. Clinics in Geriatric Medicine, 4(4), 815.
[9.] Stolley, J. M., Hall, G. R., et al. (1993). Managing the care of patients with irreversible dementia during hospitalization for comorbidities. Nurs. Clin. North Am., 28(4), 767.
[10.] Hickey, J. V. (1992). The clinical practice of neurological and neurosurgical nursing. (3rd ed.). Philadelphia: J.B. Lippincott.
COPYRIGHT 1996 Medical Economics Publishing
COPYRIGHT 1997 Information Access Company