Evaluating Symptoms of Alzheimer’s and Dementia
Such grids have assumed a more routine role in the care of dementia patients today. But through personal experience my sister and I learned that gaps exist in some nursing settings. Our seventy-five-year-old father had been diagnosed with multi-factorial dementia and a minor CVA; he became a resident of a skilled nursing and Alzheimer’s unit in a Midwest nursing facility. The facility’s psychologist had diagnosed our father as depressed and placed him on medication for aggression and anxiety. Nursing staff failed to address emotional needs or other physical behavior, resulting in a widening chasm of miscommunication that resulted in their missing a significant series of medical symptoms in his overall condition.
When we finally had him taken by ambulance to the hospital emergency room, he had a sizable bed sore on his spine, an undiagnosed fractured hip that prevented him from walking, several broken ribs in various stages of healing, and a rather serious state of malnourishment and dehydration. Though my sister and I visited every week and had brought our concerns to various members of the staff, including the head nurse, the social worker, several nurses and aides, and his physician, all responded by saying things like “He probably had a mini-stroke,” “Deterioration is part of Alzheimer’s, you know,” and “His inability to move just means his arthritis is acting up.” When we tried to tell the staff that his gray face, grimace, lethargy, and unstable gait were serious symptoms that suggested a significant decline in his condition, we were reassured that these things were reported to the doctor over a 14-day period. But nurses and doctor failed to realize the urgency of his condition. Alarmed, we had him taken to the hospital for diagnosis and treatment, and then moved him to another facility. It wasn’t until after his death that we learned our father had fallen more than a dozen times at the first facility, had been found unresponsive by nursing staff on several occasions, and had been given drugs he was allergic to that led to volatile outbursts. Only belatedly did the entire picture come into focus. Clearly, our father had been misunderstood and overlooked by the people we trusted-and paid well-for his care.
Shortly after my father’s symptoms became apparent, he came to live with me for several months. But when he began wandering at night, that is when my sister and I found it necessary to place him in assisted living. But after a month in that unit, the head nurse recommended that he be moved to skilled nursing, where he could be monitored more closely and given greater assistance. My sister worked nights and lived four hours away, so she could not take him into her home at that time. Reluctantly we placed him in the nursing facility and did our best to facilitate his adjustment by mediating his symptoms with caregivers.
When evaluating a dementia patient who is unable to clearly communicate daily needs or acute symptoms, the attending nurse should be prepared to consult a checklist or communication grid to determine the patient’s condition and possible source of changed behavior. If the facility where the nurse is employed does not provide a useful checklist, the staff member should be able to compile one that may suit the needs of a range of dementia patients. Rebecca Oberg, R.N., recommends a review of the following possible indicators as charted by the nurse:
Ã?· Vital signs. Blood pressure, heart rate, temperature, and respirations should be noted whenever a dementia patient appears agitated or “not himself.” Measurable changes in the vital signs should be further considered in conjunction with other possible symptoms when the patient is unable to communicate due to verbal or mental alterations, as was the case with our father.
�· Blood sugar. Patients with diabetes that requires periodic finger sticks may need an additional finger stick to rule out blood sugar abnormalities. Low readings may be manifested in the patient acting as though he or she were drunk with slurred speech and an unsteady gait. High readings may progress to polyphagia, polyuria, and polydipsia. Our father had abnormal blood sugar readings that were not treated or reported to the doctor.
Ã?· Color, complexion, pallor. A change in the patient’s usual skin color may suggest a circulatory alteration with possible cardiac involvement. Low blood pressure, illness, and other conditions likewise may impact the skin color. Dad’s face was ashen on two or more occasions, but the nursing staff did not find this a significant symptom in failing to coordinate it with other findings at the time.
Ã?· Facial expressions. Furrowed brows, grimacing, clenching, squinting, or weeping may suggest extreme emotion or pain. Our dad’s face displayed a painful grimace for most of the last two weeks of his stay at the facility, but again, the nurses did not find that significant, even though he was no longer able to ambulate independently as before.
Ã?· Verbal outbursts (“word salad”) often depict a patient in distress who is trying to convey a message to others. This was often the case with our family member, and though these events were charted, they did not elicit further medical follow-up.
Ã?· Medications. Review all medicines and prescriptions the patient is taking and check for correct dosages, side effects, adverse reactions, and allergies. Don’t depend on the pharmacy to catch any contraindications. Our father was given certain drugs that resulted in the opposite response desired, including toxic blood levels of some medications.
Our father exhibited most of the following symptoms as well:
Ã?· Unsteady gait, limping, slow movements. Patients who typically ambulate in a certain fashion and demonstrate a change in movement should be evaluated for a change in overall condition or mental status. Never write off these changes as someone having “a bad day” or “a slow start.” While either may be true, it is only fair to thoroughly evaluate the patient for underlying causes.
Ã?· Altered appetite. While it is true that Alzheimer’s patients or those with dementia typically experience a decrease in appetite as the disease progresses, a reduced appetite may signal other disorders as well. Malnourishment will result if a patient is unable to eat in a healthy manner, so look for possible contributing causes to a change in appetite.
�· Altered bowel and bladder habits. Even dementia patients experience occasional changes in their toileting habits. But prolonged or serious changes need to be checked to rule out the potential for a serious underlying condition.
Ã?· Physical appearance. If the patient “looks funny,” either through bodily symptoms or movements or even in the way he or she is dressed, take a second or third look. Altered mental status, such as a stroke or TIA, may lead the patient to unexpectedly change the usual manner of dress, bearing, or behavior. Don’t chalk up such changes as a fluke. Check them out.
Ã?· Increased confusion, agitation, or altered mental status. For example, the patient who always recognizes his visiting daughter today does not know her. Or someone who typically enjoys dessert has stopped caring. Pronounced depression, fits of weeping or sobbing, etc., may suggest a serious change in the patient’s mental condition.
�· Increased lethargy. Patients who do not rouse easily in the morning, who take more naps than before or longer naps than previously, or who seem sleepy or fatigued a good part of the day may require special medical attention.
�· Change in sleep habits. When a patient sleeps more or less than is usual, something may be amiss. Physical or emotional discomfort should be evaluated.
�· Change in social activity. A decrease or halt to social interaction suggests the need for medical follow-up. It may be that the patient is experiencing a temporary decrease in social interests, but there also may be a problem in another area that requires medical examination.
�· General illness. Nausea and vomiting, temperature change, cool or clammy skin, or other bodily symptoms of illness need to be evaluated by a nurse or a doctor. While these may point to a potentially minor condition, such as a virus, that is easily treated, they likewise may herald a more serious disorder that needs to be diagnosed and treated.
Go with your gut. Occasionally a nurse may sense something different about a patient without being able to articulate exactly what it is. Such feelings deserve follow-up. Continue observing the patient to see if your gut feeling pans out. If there is something wrong, it should become clearer with time.
Each patient should have an individualized plan of care that everyone involved is familiar with: the patient and family members, the medical staff, and the administrators if the situation occurs in a nursing facility.
All patients will require adjustments in the individual plan of care. But most situations should include a consistent charting and reporting path to keep everyone informed of changes in the patient’s health.
If you do not have a checklist or grid to follow when assessing a patient’s change in condition, suggest one to the patient’s family, home health care nurse, or facility administrator. Then work with other staff members to develop a comprehensive checklist and care plan that will help to address typical symptoms of the patients. You may have to adjust it periodically as new observations or symptoms appear.
Also be sure that the reporting path is clearly outlined and understood among all involved persons. There should be no questions when the patient’s condition suddenly changes. Everyone should know what to expect in terms of noting changes and calling the doctor or notifying the family. Don’t be afraid to contact the physician on call even if it’s three a.m. As long as you have a good rationale for your concern, the doctor will admire and grow to depend on your wise judgment. Be an advocate for your patient.
Making a few simple changes in the way that you assess a patient’s non-verbal cues may make the difference to a patient’s quality of life and his or her family’s peace of mind. Had our father’s symptoms been consistently charted, reported, and acted on, he might still be here today. Get started now to organize this critical information and provide your patients with the highest possible level of communicative interaction.
