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Measuring improvement in patients with dementia
Measuring Improvement in Patients with Dementia Do lecithin and physostigmine in combination aid memory? This pilot study suggests they do. It also introduces a quick, reliable nursing tool to measure patients' progress.
MAGGIE ANTOINE CYNTHIA HOLLAND BEATRICE SCRUGGS Poor memory is often mistakenly regarded as an inevitable and irreversible accompaniment of old age. This false impression not only increases each person's fear of growing old but also leads caregivers to react inappropriately to the forgetful or confused elderly patient. Research indicates that only certain aspects of memory may decline with advanced age. Research further reveals, however, that memory loss is one characteristic of senile dementia, which is perhaps the most distressing, and frightening spectre for all people. The effect of the memory impairMaggie Antoine, RN, MS(ed), an adult health nurse practitioner, is assistant director. Geriatric Psychosocial Rehabilitation Unit; Cynthia Holland, RN, MSN, is a gerontological clinical nurse specialist; and Beatrice Scruggs, RN, MSN, is a clinical nurse specialist. oncology. All are on the staff of the Tuskegee Veterans Administration Medical Center in Alabama. The authors extend appreciation to David Tull, MD. director of the VAMC. for his support in the use of the evaluation tool they describe.
ment of senile dementia on functional capacity in activities of daily living was the main reason for a clinical project we conducted at the Veterans Administration Medical Center in Tuskegee, Alabama. This pilot study was undertaken to measure improvement, if any, in memory, communication, and selfcare ability in elderly men receiving lecithin and physostigmine; and to validate the reliability of the nursing tool used to make these measurements. Rationale for Therapy The neurotransmitter acetylcholine is important to memory. Choline and lecithin, which are precursors to acetylcholine, have been given in attempts to increase concentrations of acetylcholine in the brain's cholinergic system, but without success, at least in Alzheimer's disease(l). However, the drug physostigmine, which reduces the degradation of acetycholine, has been found, when administered alone or with lecithin, to improve memory in patients with senile dementia of the Alzheimer's type(2). Theoretically, lecithin and physo-
stigmine act synergistically to improve memory, lecithin increasing the synthesis and release of acetylcholine, physostigmine inhibiting its breakdown(3-4). Presumably; an improvement in memory should increase the aged person's ability to recall recent events; perform self-care, and communicate. The tool chosen to measure this change was the "Nursing Evaluation: Progress of Activities of Daily Living, Orientation, Communication, and Behavior." Originally developed at the Tuskegee VAMC to categorize patients' functional state, the tool was refined for the pilot study. The Pilot Study This clinical investigation was conducted on one ward of a 235bed intermediate medicine unit designated for the long-term rehabilitation of the elderly, the blind, and medical patients. All patients in the pilot study were housed on ward 62-3 in order to keep constant such factors as staff, wardmates, the immediate living environment, meals and medication schedules, and group activities.
Geriatric Nursing July/August 1986 185
Nine patients with varying levels of mental deficits were selected from this ward using the following criteria: • an established diagnosis of mild-to-moderate senile dementia • no active psychosis • no associated ethanol abuse • no coexisting cerebrovascular accident, seizure disorder, severe hypertension, uncontrolled diabetes mellitus, Huntington's chorea, acute myocardial infarction, or asthma • ability to withstand discontinuation of all previously prescribed medications both before and during
the entire investigational period • ability to participate by giving verbal or nonverbal responses. Verbal explanations were given to patients, their families, or both regarding the clinical evaluation, and consent was obtained for modifications of the patients' drug regimens. All the patients were men; ages ranged from 61 to 84: Their demographic characteristics appear in the table. One month before the study began, all medications prescribed for these men were discontinued. At the end of that month, one baseline score was obtained for
RS G EVAL ATIO : Activities of Daily Living. Orient tion, Communication, and Be no Patient's Name:
Age: Birthdate: Sex:
Date Admitted to Program:
.
On the basis of behavior you have assessed, code as follows: 1. Dependent, 2. Needs Assistance, or 3. Independent.
Washes hands and faoe Bathes-showers Shaves=-makeup Cleans teeth-dentures Combs hair 2. DRESSING Puts on shIrt top
.' Puts on bottoms Puts on shoes-socks
..
Fastens buttons 3. TOILETJNG Incontinent of Bladder
Incontinent of Bowel Toilets w I assistance Toilets independently 4. EATING
•.
Drinks from glass Uses spoon Uses fork Uses knife Eats most of food
.
Feeding 1. What is the name of the presentPresident? 2. Who is the Vice President? 3. How many weeks are there in a year?
186 Geriatric Nursing July/August 1986
each man, using the "Nursing Evaluation" (see illustration). Observations and assessments were scored for each of the 61 items as follows: 1 point-dependent; 2 points-needs assistance, and 3 points-independent. The possible scoring ranges were: Independent: 145 to 186.0 Needs Assistance: 103 to 144.9 Dependent: 64 to 102.9 The "Nursing Evaluation" permits systematic rating of the patient's ability in performing activities of daily living, in orientation, communication, and behavior. Even though basic orientation can be seen as subjective, the patient's responses can be validated easily. In an attempt to objectively evaluate the patient's interaction with others, items observed are rated under communication and behavior. The score each man achieved on this single evaluation became his baseline (see Patient Scores on Nursing Evaluation). Next, a daily regimen was established with the oral administration of lecithin (an acetylcholine precursor) and physostigmine (an anticholinesterase) for 30 days. Lecithin 20 gm was administered three times a day with meals and physostigmine 1 mg twice a day, at breakfast and supper. No other drugs were administered during this period. For the next 30 days each patient was evaluated with the "Nursing Evaluation" twice daily, at 10:00 AM and 7:00 PM, one hour after the physostigmine was given. The rationale for evaluation at this time was because of the rapid metabolism of physostigmine (60 to 120 minutes)(5). In a 20-minute interview, the patients were asked to read a reality orientation board and the correct time on a standard size wall clock, to identify familiar objects in the immediate environment, give the first name of their closest relative, and follow a simple instruction on request, that is "Introduce yourself to your roomate." Responses to items about the patient's participation in ADL were checked with the assigned nursing staff.
All interviews were conducted by the clinical nursing instructor for long-term care, the nurse practitioner assigned to the designated ward, and the clinical nurse specialist in gerontology. They achieved some degree of objectivity by agreeing on consistency in the interviewing process and by using standardized phrases and props. Once a week, the nine patients were rated by a different interviewer.
Using a consistent tool for scoring ADL enables treatment evaluation. After the 30-day period of lecithin and physostigmine, the same nursing evaluations of the patients were conducted in the same manner for another 30 days. Results Of the nine patients, four (patients E, F, H, and I) were in the independent category as evaluated before the administration of lecithin and physostigmine. Their scores were 145 or higher. The mean scores of these four men during the 30 days after lecithin and physostigmine were stopped demonstrated further increases in ADL ability, communication skills, and orientation (see Scores on Nursing Evaluation). Patient A progressed from his baseline category of "needs assistance" to being independent. Two men (D, G) whose baseline scores were in the needs assistance category remained in this range. Both D and G showed improvement during the second evaluation period in communication and orientation, but they experienced decrements in ADL and behavior during the third evaluation period. Patient B, dependent on baseline evaluation, became more dependent on each succeeding evaluation. Patient C's initial "needs assistance" score, declined at second
5. MOBILITY Gena nc c haIr Can stand Can walk w/assistance Ambulates independently Uses w)chair independ. 6. ORIENTATlON-PART I
~-
"\-.1
'• •
~ ~;J:' • • • :¥.,
?:" :l~. ..
Oriented to person Oriented to place Oriented to time • Oriented to current events 7. BASIC ORIENTATION-Part II Responds to own name Knows own name Knows date Knows year Knows next meal Knows next holiday Knows month , Knows 'hospital Knows city '"' Knows state Knows one staff member Knows assigned nurse Knows one patieht Knows family members Knows familiar objects (alarm clock, soap, matches) Knows past occupation Knows home town Knows doctor Reads A.O. board alone Reads A.O. board w/help Correctly telts time 8. COMMUNICATION
.
Speaks clearly to: staff voluntarily. staff when asked Visitors voluntarily visitors when asked patients voluntarily patients when asked !). BEHAVIOR
..
-
-
- -
..
"
. .-
~
, "-
~
.,
- -
,.
Displays disruptive behavior Performs small tasks 'Helps others Attends available activities Read or watches TV TOTAL SCORE:
.
.
\'
~
INITIALS:
Geriatric Nursing July/August 1986 187
evaluation, but reached 145, independent, at the third evaluation. Mean scores for six men, A, D, F, G, H, and I improved in the 30 days posttherapy, most dramatically for patients F, H, and 1. We believe the tool "Nursing Evaluation" accurately measured the boundaries between dependence, semidependence, and independence. Following this clinical evaluation, completed in January 1981, our monthly evaluations of identified functional categories, using this tool, have revealed consistent delineation of the boundaries between these levels of performance. Limitations Two elements of this clinical investigation deserve particular discussion: the size of the sample and the quality of the interactions between patients and staff. First, the selection of patients even from a large long-term care population, was difficult because of the numbers and types of coexisting mediCal conditions in the ward population. Changes associated with aging are rarely single, whether
SCORES ON NURSING EVALUATlON (N
=
9)
Patient Baseline 30 DAYS 30 DAYS (oneDrug Post therapy time) therapy A
.B
C D E
F G H I
134 74 144 125 146 153 111 155 151
(mean) 144.3 70.6 133.6 132.1 138.4 169.7 127.3 162.6 154.1
(mean) 153 64 145 132 147.33 177.8 111.8 165 155.8
Baseline scores represent a one·time assessment done one month after the patients were taken off medication, immediately before the administration of lecithin and physostigmine, which were given twice daily for 30 days. During that period, patients were evaluated twice daily. After the drugs were stopped, patients were evaluated twice daily for another 30 days.
such alterations are normal, pathological, or socially induced(6). Although a larger sample population would have been desirable, a greater number of persons with minimum physical and emotional problems probably would not be in-
stitutionalized for 24-hour care and services. Second, the quality and quantity of interactions with the interviewers on a consistent basis for two months afforded more communication and socialization for the nine patients than their ward mates received. Also, it was occasionally necessary to return to a patient a second time within the two-hour period postmedication if the patient chose not to respond at the initial session. Another factor influencing the quality of interaction was the extra attention given these nine patients in the form of encouragement and reinforcement of reality orientation, which helped them relate better with roommates and increased familiarity with their personal living space. Diminished sensory perception and variations in usual personal characteristics and moods were noted in afternoon sessions and when weather was inclement compared to interviews conducted in the morning or when the weather was fair. Thus, time of day probably affected performance. The tool itself was not sensitive
DEMOGRAPHIC CHARACTERISTICS OF PATIENTS
RACE
YEARS OF HOSPITALIZArrO nIAGNOSIS
MOBILITY
OCCUPATION
married
Black
44
paranoid· schizophrenia
ambulatory
railroad worker
65
married
Caucasian
3
psychosis· organic brain syndrome
wheelchair
plpefitter
C
79
divorced
Black
1.5
OBS
ambulatory
yardman) railroad
D
78
married
Caucasian
3
OBS
ambulatory
attorney
E
62
single
Caucasian
3
catatonic· schizophrenia
ambulatory
farmer
F
68
married
Caucasian
OBS
ambulatory
watch smith
G
-- -
74
married
Caucasian
1.5
OBS
ambulatory
unknown
H
74
married
Caucasian
2
OBS
ambulatory
furniture repair
I
61
single
Black
33
Neurosyphilis, meningoencephalitic type
ambulatory
high school instructor
PATIENT AGE
MARITAL STATUS
A
84
B
1
--
-Psychotic manifestations were inactive at the time of the pilot study.
188 C1eriatric Nursing July/August 1986
GRAPHIC COMPARISON OF SCORES for Nine Patients -_.- ....
--_.
180 175 110 165 180 155 150 145
140
135 130 125 120 '115 110 105
..
...
r--
r-r--
r--
-
r--
,......
r--
r--
r--
-
,.--r--
-
r--
-
-
80 15 70 65 80
A KEY:
:nnn B
D
Baseline· one·time sCOIe 30 days after all medications slopped
o
o
E •
•F
Nursing Implications The belief that elders suffering from senile dementia can do nothing for themselves is a myth. The complex interplay of physical, emotional, and social factors is often ignored and all mental changes regarded as irreversible, and therefore untreatable. Contrary to these beliefs, this clinical evaluation showed that at least some older demented patients can and do improve moderately in memory, communication, behavior, and activities of daily living as a result of care; and can be and are responsive to individual and group socialization. The progress of some elderly senile dementia individuals from a dependent to semiindependent level may be realistic when a consistent, repetitive nursing program is maintained. The "Nursing Evaluation" can
,..:-
Summary The evaluation of data compiled on nine patients whose behaviors and activities were monitored while on a regimen of lecithin and physostigmine indicated a modest improvement in performance of ADL. Further analysis of the data revealed continued improvement in
H
.1
ScoringRange Independent: 145 10 186 Needs assistance: 103 to 144.9 Dependent: 6 to 102.9
Mean score during administration of lecithin and p ysostig Ine lor 30 days
monitor performance accurately and measure progress in such programs. Use of the tool enables nurses to assess sensory, motor, and cognitive deficits as the basis for appropriate"intervention. In light of the limited formal education of some elders, however, specific questions, such as "How many weeks are there in a year?" May require modification to reflect life experiences. Also, it is well to remember that there maybe a discrepancy between what a memoryimpaired person may say and what he or she is capable of doing. Tariot and others point out that "the patient who 'can't cook' in the average cluttered kitchen might open a can of soup and heat it if the implements were laid out(?)."
r--
. • G ..
Mean score during 30 days after medication stopped
to these time-of-day changes. However, familiarity with the patients enabled us to see the need for flexibility during the interview. Another study would be necesary to determine the degree of effect.
-
-
-
-
100 95 90 85
-
eight patients from baseline to the end of the poststudy period. During the clinical evaluation, individual physical changes and variations in response to socioenvironmental factors on three patients (C, 0, and G) influenced the results in a nonsupportive direction. The "Nursing Evaluation" proved to be a quick, reliable indicator of the patient's total functioning ability. References I. Bartus, R. T.• and others. Thc cholinergic hy-
2.
3. 4. 5.
6.
7.
pothesis of geriatric memory dysfunction. Science 217:408-414. July 30, 1982. Brinkman. S. D.• and Gershon. S. Mcasurement of cholinergic drug cffects on mcmory in Alzheimcr's discasc. Neurobiol.Aging 4:139· 145, Summcr 1983. Lccithin and memory. Lancer (cditorial) 1:293. Fcb. 9, 1980. Wolanin, M. 0., and Phillips, L. R. Confusion: Prevention and Care. St. Louis, The C. V. Mosby Co., 1981. pp. 33-36. Joncs, O'N., and Fcldman Pharmaceuticals. "Antilirium" (Physostigminc salicylatc.) IN Physicians' Desk Reference. 35th ed. Oradell, NJ. Mcdical Economics Co.• 1981. p. 1290. Rossman. Isadore. Options for care of the aged sick. IN The Geriarric Patienr. ed. by William Reichel and Mal Schechter. Tucson, AZ. H. P. Publishing Co., 1978, pp. 33-37. Tariot, P., and others. How memory fails: a thcoretical modcl. Geriatr.Nurs. 6:144-147. May·June 1985.
Geriatric Nursing July/August 1986 189
MAGGIE ANTOINE CYNTHIA HOLLAND BEATRICE SCRUGGS Poor memory is often mistakenly regarded as an inevitable and irreversible accompaniment of old age. This false impression not only increases each person's fear of growing old but also leads caregivers to react inappropriately to the forgetful or confused elderly patient. Research indicates that only certain aspects of memory may decline with advanced age. Research further reveals, however, that memory loss is one characteristic of senile dementia, which is perhaps the most distressing, and frightening spectre for all people. The effect of the memory impairMaggie Antoine, RN, MS(ed), an adult health nurse practitioner, is assistant director. Geriatric Psychosocial Rehabilitation Unit; Cynthia Holland, RN, MSN, is a gerontological clinical nurse specialist; and Beatrice Scruggs, RN, MSN, is a clinical nurse specialist. oncology. All are on the staff of the Tuskegee Veterans Administration Medical Center in Alabama. The authors extend appreciation to David Tull, MD. director of the VAMC. for his support in the use of the evaluation tool they describe.
ment of senile dementia on functional capacity in activities of daily living was the main reason for a clinical project we conducted at the Veterans Administration Medical Center in Tuskegee, Alabama. This pilot study was undertaken to measure improvement, if any, in memory, communication, and selfcare ability in elderly men receiving lecithin and physostigmine; and to validate the reliability of the nursing tool used to make these measurements. Rationale for Therapy The neurotransmitter acetylcholine is important to memory. Choline and lecithin, which are precursors to acetylcholine, have been given in attempts to increase concentrations of acetylcholine in the brain's cholinergic system, but without success, at least in Alzheimer's disease(l). However, the drug physostigmine, which reduces the degradation of acetycholine, has been found, when administered alone or with lecithin, to improve memory in patients with senile dementia of the Alzheimer's type(2). Theoretically, lecithin and physo-
stigmine act synergistically to improve memory, lecithin increasing the synthesis and release of acetylcholine, physostigmine inhibiting its breakdown(3-4). Presumably; an improvement in memory should increase the aged person's ability to recall recent events; perform self-care, and communicate. The tool chosen to measure this change was the "Nursing Evaluation: Progress of Activities of Daily Living, Orientation, Communication, and Behavior." Originally developed at the Tuskegee VAMC to categorize patients' functional state, the tool was refined for the pilot study. The Pilot Study This clinical investigation was conducted on one ward of a 235bed intermediate medicine unit designated for the long-term rehabilitation of the elderly, the blind, and medical patients. All patients in the pilot study were housed on ward 62-3 in order to keep constant such factors as staff, wardmates, the immediate living environment, meals and medication schedules, and group activities.
Geriatric Nursing July/August 1986 185
Nine patients with varying levels of mental deficits were selected from this ward using the following criteria: • an established diagnosis of mild-to-moderate senile dementia • no active psychosis • no associated ethanol abuse • no coexisting cerebrovascular accident, seizure disorder, severe hypertension, uncontrolled diabetes mellitus, Huntington's chorea, acute myocardial infarction, or asthma • ability to withstand discontinuation of all previously prescribed medications both before and during
the entire investigational period • ability to participate by giving verbal or nonverbal responses. Verbal explanations were given to patients, their families, or both regarding the clinical evaluation, and consent was obtained for modifications of the patients' drug regimens. All the patients were men; ages ranged from 61 to 84: Their demographic characteristics appear in the table. One month before the study began, all medications prescribed for these men were discontinued. At the end of that month, one baseline score was obtained for
RS G EVAL ATIO : Activities of Daily Living. Orient tion, Communication, and Be no Patient's Name:
Age: Birthdate: Sex:
Date Admitted to Program:
.
On the basis of behavior you have assessed, code as follows: 1. Dependent, 2. Needs Assistance, or 3. Independent.
Washes hands and faoe Bathes-showers Shaves=-makeup Cleans teeth-dentures Combs hair 2. DRESSING Puts on shIrt top
.' Puts on bottoms Puts on shoes-socks
..
Fastens buttons 3. TOILETJNG Incontinent of Bladder
Incontinent of Bowel Toilets w I assistance Toilets independently 4. EATING
•.
Drinks from glass Uses spoon Uses fork Uses knife Eats most of food
.
Feeding 1. What is the name of the presentPresident? 2. Who is the Vice President? 3. How many weeks are there in a year?
186 Geriatric Nursing July/August 1986
each man, using the "Nursing Evaluation" (see illustration). Observations and assessments were scored for each of the 61 items as follows: 1 point-dependent; 2 points-needs assistance, and 3 points-independent. The possible scoring ranges were: Independent: 145 to 186.0 Needs Assistance: 103 to 144.9 Dependent: 64 to 102.9 The "Nursing Evaluation" permits systematic rating of the patient's ability in performing activities of daily living, in orientation, communication, and behavior. Even though basic orientation can be seen as subjective, the patient's responses can be validated easily. In an attempt to objectively evaluate the patient's interaction with others, items observed are rated under communication and behavior. The score each man achieved on this single evaluation became his baseline (see Patient Scores on Nursing Evaluation). Next, a daily regimen was established with the oral administration of lecithin (an acetylcholine precursor) and physostigmine (an anticholinesterase) for 30 days. Lecithin 20 gm was administered three times a day with meals and physostigmine 1 mg twice a day, at breakfast and supper. No other drugs were administered during this period. For the next 30 days each patient was evaluated with the "Nursing Evaluation" twice daily, at 10:00 AM and 7:00 PM, one hour after the physostigmine was given. The rationale for evaluation at this time was because of the rapid metabolism of physostigmine (60 to 120 minutes)(5). In a 20-minute interview, the patients were asked to read a reality orientation board and the correct time on a standard size wall clock, to identify familiar objects in the immediate environment, give the first name of their closest relative, and follow a simple instruction on request, that is "Introduce yourself to your roomate." Responses to items about the patient's participation in ADL were checked with the assigned nursing staff.
All interviews were conducted by the clinical nursing instructor for long-term care, the nurse practitioner assigned to the designated ward, and the clinical nurse specialist in gerontology. They achieved some degree of objectivity by agreeing on consistency in the interviewing process and by using standardized phrases and props. Once a week, the nine patients were rated by a different interviewer.
Using a consistent tool for scoring ADL enables treatment evaluation. After the 30-day period of lecithin and physostigmine, the same nursing evaluations of the patients were conducted in the same manner for another 30 days. Results Of the nine patients, four (patients E, F, H, and I) were in the independent category as evaluated before the administration of lecithin and physostigmine. Their scores were 145 or higher. The mean scores of these four men during the 30 days after lecithin and physostigmine were stopped demonstrated further increases in ADL ability, communication skills, and orientation (see Scores on Nursing Evaluation). Patient A progressed from his baseline category of "needs assistance" to being independent. Two men (D, G) whose baseline scores were in the needs assistance category remained in this range. Both D and G showed improvement during the second evaluation period in communication and orientation, but they experienced decrements in ADL and behavior during the third evaluation period. Patient B, dependent on baseline evaluation, became more dependent on each succeeding evaluation. Patient C's initial "needs assistance" score, declined at second
5. MOBILITY Gena nc c haIr Can stand Can walk w/assistance Ambulates independently Uses w)chair independ. 6. ORIENTATlON-PART I
~-
"\-.1
'• •
~ ~;J:' • • • :¥.,
?:" :l~. ..
Oriented to person Oriented to place Oriented to time • Oriented to current events 7. BASIC ORIENTATION-Part II Responds to own name Knows own name Knows date Knows year Knows next meal Knows next holiday Knows month , Knows 'hospital Knows city '"' Knows state Knows one staff member Knows assigned nurse Knows one patieht Knows family members Knows familiar objects (alarm clock, soap, matches) Knows past occupation Knows home town Knows doctor Reads A.O. board alone Reads A.O. board w/help Correctly telts time 8. COMMUNICATION
.
Speaks clearly to: staff voluntarily. staff when asked Visitors voluntarily visitors when asked patients voluntarily patients when asked !). BEHAVIOR
..
-
-
- -
..
"
. .-
~
, "-
~
.,
- -
,.
Displays disruptive behavior Performs small tasks 'Helps others Attends available activities Read or watches TV TOTAL SCORE:
.
.
\'
~
INITIALS:
Geriatric Nursing July/August 1986 187
evaluation, but reached 145, independent, at the third evaluation. Mean scores for six men, A, D, F, G, H, and I improved in the 30 days posttherapy, most dramatically for patients F, H, and 1. We believe the tool "Nursing Evaluation" accurately measured the boundaries between dependence, semidependence, and independence. Following this clinical evaluation, completed in January 1981, our monthly evaluations of identified functional categories, using this tool, have revealed consistent delineation of the boundaries between these levels of performance. Limitations Two elements of this clinical investigation deserve particular discussion: the size of the sample and the quality of the interactions between patients and staff. First, the selection of patients even from a large long-term care population, was difficult because of the numbers and types of coexisting mediCal conditions in the ward population. Changes associated with aging are rarely single, whether
SCORES ON NURSING EVALUATlON (N
=
9)
Patient Baseline 30 DAYS 30 DAYS (oneDrug Post therapy time) therapy A
.B
C D E
F G H I
134 74 144 125 146 153 111 155 151
(mean) 144.3 70.6 133.6 132.1 138.4 169.7 127.3 162.6 154.1
(mean) 153 64 145 132 147.33 177.8 111.8 165 155.8
Baseline scores represent a one·time assessment done one month after the patients were taken off medication, immediately before the administration of lecithin and physostigmine, which were given twice daily for 30 days. During that period, patients were evaluated twice daily. After the drugs were stopped, patients were evaluated twice daily for another 30 days.
such alterations are normal, pathological, or socially induced(6). Although a larger sample population would have been desirable, a greater number of persons with minimum physical and emotional problems probably would not be in-
stitutionalized for 24-hour care and services. Second, the quality and quantity of interactions with the interviewers on a consistent basis for two months afforded more communication and socialization for the nine patients than their ward mates received. Also, it was occasionally necessary to return to a patient a second time within the two-hour period postmedication if the patient chose not to respond at the initial session. Another factor influencing the quality of interaction was the extra attention given these nine patients in the form of encouragement and reinforcement of reality orientation, which helped them relate better with roommates and increased familiarity with their personal living space. Diminished sensory perception and variations in usual personal characteristics and moods were noted in afternoon sessions and when weather was inclement compared to interviews conducted in the morning or when the weather was fair. Thus, time of day probably affected performance. The tool itself was not sensitive
DEMOGRAPHIC CHARACTERISTICS OF PATIENTS
RACE
YEARS OF HOSPITALIZArrO nIAGNOSIS
MOBILITY
OCCUPATION
married
Black
44
paranoid· schizophrenia
ambulatory
railroad worker
65
married
Caucasian
3
psychosis· organic brain syndrome
wheelchair
plpefitter
C
79
divorced
Black
1.5
OBS
ambulatory
yardman) railroad
D
78
married
Caucasian
3
OBS
ambulatory
attorney
E
62
single
Caucasian
3
catatonic· schizophrenia
ambulatory
farmer
F
68
married
Caucasian
OBS
ambulatory
watch smith
G
-- -
74
married
Caucasian
1.5
OBS
ambulatory
unknown
H
74
married
Caucasian
2
OBS
ambulatory
furniture repair
I
61
single
Black
33
Neurosyphilis, meningoencephalitic type
ambulatory
high school instructor
PATIENT AGE
MARITAL STATUS
A
84
B
1
--
-Psychotic manifestations were inactive at the time of the pilot study.
188 C1eriatric Nursing July/August 1986
GRAPHIC COMPARISON OF SCORES for Nine Patients -_.- ....
--_.
180 175 110 165 180 155 150 145
140
135 130 125 120 '115 110 105
..
...
r--
r-r--
r--
-
r--
,......
r--
r--
r--
-
,.--r--
-
r--
-
-
80 15 70 65 80
A KEY:
:nnn B
D
Baseline· one·time sCOIe 30 days after all medications slopped
o
o
E •
•F
Nursing Implications The belief that elders suffering from senile dementia can do nothing for themselves is a myth. The complex interplay of physical, emotional, and social factors is often ignored and all mental changes regarded as irreversible, and therefore untreatable. Contrary to these beliefs, this clinical evaluation showed that at least some older demented patients can and do improve moderately in memory, communication, behavior, and activities of daily living as a result of care; and can be and are responsive to individual and group socialization. The progress of some elderly senile dementia individuals from a dependent to semiindependent level may be realistic when a consistent, repetitive nursing program is maintained. The "Nursing Evaluation" can
,..:-
Summary The evaluation of data compiled on nine patients whose behaviors and activities were monitored while on a regimen of lecithin and physostigmine indicated a modest improvement in performance of ADL. Further analysis of the data revealed continued improvement in
H
.1
ScoringRange Independent: 145 10 186 Needs assistance: 103 to 144.9 Dependent: 6 to 102.9
Mean score during administration of lecithin and p ysostig Ine lor 30 days
monitor performance accurately and measure progress in such programs. Use of the tool enables nurses to assess sensory, motor, and cognitive deficits as the basis for appropriate"intervention. In light of the limited formal education of some elders, however, specific questions, such as "How many weeks are there in a year?" May require modification to reflect life experiences. Also, it is well to remember that there maybe a discrepancy between what a memoryimpaired person may say and what he or she is capable of doing. Tariot and others point out that "the patient who 'can't cook' in the average cluttered kitchen might open a can of soup and heat it if the implements were laid out(?)."
r--
. • G ..
Mean score during 30 days after medication stopped
to these time-of-day changes. However, familiarity with the patients enabled us to see the need for flexibility during the interview. Another study would be necesary to determine the degree of effect.
-
-
-
-
100 95 90 85
-
eight patients from baseline to the end of the poststudy period. During the clinical evaluation, individual physical changes and variations in response to socioenvironmental factors on three patients (C, 0, and G) influenced the results in a nonsupportive direction. The "Nursing Evaluation" proved to be a quick, reliable indicator of the patient's total functioning ability. References I. Bartus, R. T.• and others. Thc cholinergic hy-
2.
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