A ventilator-dependent 76-year-old female with COPD and dementia of the Alzheimer’s type benefitted from a combination of proper medication, adequate sleep, and a regular routine.

A 76-year-old female patient was transferred to a long-term rehabilitation facility in Kirtland, Ohio, from another health care facility due to difficulties in weaning her from ventilatory support. The patient had a long history of chronic obstructive pulmonary disease (COPD) and congestive heart failure. When admitted, the patient was placed on a ventilator with the following settings:

Spontaneous respiratory rate ranged from 10 to 15 breaths per minute. Spontaneous tidal volume ranged from 200 to 300 mL. SpO2 ranged from 92% to 96%.

The patient’s condition stabilized within several days of admission, and eventually she could tolerate being off the ventilator and on a tracheostomy collar for several hours at a time while out of bed or in a wheelchair. She also passed a swallowing evaluation administered by the speech pathologist and could occasionally communicate for short periods using a speaking valve. She was allowed to consume pureed foods and thickened liquids as tolerated.

Although she was not totally ventilator dependent during the day, she required ventilatory assistance during hours of sleep. Following the normal routine of the facility, the patient was made ready for bed around 8:00 pm. Preparation for bed generally included evening medication administration, toileting, tracheostomy care, and evening aerosol treatment (0.5 mL albuterol mixed with unit dose [.05%] ipratropium bromide). She was usually in bed and asleep by 9:00 pm or 9:30 pm.

However, it was routinely reported that she would typically reawaken by 11:30 pm or 12:00 am. At this time, she would appear to be disoriented. Often she would be found attempting to get out of bed and occasionally she would disconnect herself from the ventilator and sometimes even pull out her tracheostomy tube. When any of her caregivers expressed concern for what she was doing, the patient would immediately begin to cry and become even more difficult to deal with.

Because of the potential for self-injury, an order was obtained for low doses of both lorazepam and haloperidol. However, these did little to alter her negative behavior, and she continued to follow the same pattern until her inevitable death from pneumonia and ventilatory failure 6 months after admission.

Discussion
Besides the catastrophic lung damage from COPD that kept her more or less tied to continuous ventilatory support, this patient had a secondary diagnosis of dementia of the Alzheimer’s type (DAT). Dementia is a common problem in this country, afflicting approximately 18% to 20% of individuals over 75 years of age. It is defined as a decline in cognitive capacity, in which multiple areas of cognition are impaired while the victim retains a normal level of consciousness. The diagnosis is made based on a series of observations of typical behaviors, careful interviews made by clinicians who specialize in dementia, and sometimes through the administration of the Mini-Mental State Examination.

Some of the typical behaviors associated with dementia include the following:
• mood disturbances (depression, anxiety, or irritability);
• suspiciousness, paranoia, and delusions;
• problem behaviors (rummaging and hoarding, wandering, social withdrawal and apathy, and uncooperativeness and resistance to care); and
• disturbances of basic drives (sexual disorders, sleep disorders, and eating disorders).

The patient exhibited many of these behaviors—most notably wandering, mood disturbances, and resistance to care. Likewise, when confronted with her behavior, she also exhibited another key component of dementia—the catastrophic reaction. This is defined as a sudden expression of negative emotion that is precipitated by an environmental event or a task failure.

As a rule, dementia of the Alzheimer’s type progresses through seven stages, based on loss of functional abilities. Generally, by the time patients reach stage 6, they require 24-hour supervision and may need to be placed in a long-term care facility. In addition, to further compound the problem, patients with dementia are also very vulnerable to other illnesses (comorbidity). The presence of any comorbid medical illness and/or the use of medications in this type of patient often results in a worsening of the cognitive symptoms, the development of delirium, the onset of behavioral symptoms, or further decline.

RT’s role in Dementia Care
Researchers are exploring new ways to stop and even reverse the progression of DAT. However, at present, most care is directed toward minimizing symptoms and providing comfort measures and supportive care, while maintaining a safe and nurturing environment. For the RT, this often means integrating normal respiratory care procedures with treatments and care provided by other caregivers. It also means attempting to understand the problems associated with caring for a patient with DAT and assisting the other caregivers in monitoring patients and observing changes in basic behavior, which may signal a further decline in the patient’s condition. The therapist may also need to look at the medications given for the dementia and determine how these will interact with the patient’s underlying cardiopulmonary status (does the medication promote respiratory depression, etc).

The following is a list of basic principles in caring for patients with DAT, which should be of interest and concern to RTs working directly with these patients:
• learn as much as you can about the patients, including their cognitive abilities, their problem behaviors, the medications they are receiving, and their personal history.
• make a determined effort to communicate. For patients with advanced DAT, this means making eye contact to ensure that the patient can both see and hear you
• provide for adequate sleep. This might mean maintaining a regular sleep schedule, minimizing loud noises and bright lights, and keeping the patient physically comfortable during hours of sleep. Also, quite often patients with DAT will wake up at night and express fear and disorientation. When this occurs, sometimes simply providing reassurance will help them go back to sleep.
• establish a regular routine. The more routines are repeated and reinforced by the environment, the greater the likelihood that the patient will adapt to the surroundings.
• assess for patient tiredness and encourage daytime naps.1-3

Conclusion
Working with patients with DAT can be frustrating and both physically and mentally challenging for the caregiver. Sometimes discussing these demands with colleagues can reduce stress.

For the RT, who often must integrate critical respiratory procedures with other treatments, the situation can be equally frustrating. The therapist should attempt to understand the nature of the dementia and the associated treatment, and to assist the other caregivers in providing surveillance and basic care whenever possible.

William A. French, MA, RRT, is clinical director and assistant professor, Respiratory Therapy Program, Lakeland Community College, Kirtland, Ohio.

References
1. Rabins PV, Lyketsos CG, Steele CD. Practical Dementia Care. Oxford, England: Oxford University Press; 1999.
2. Alexopoulos GS, Silver JM, Kahn DA, Frances A, Carpenter D. The Expert Consensus Guideline Series: agitation in older persons with dementia. A postgraduate medicine special report [Psychguides Web site]. April 1, 1998. Available at: www.psychguides.com. Accessed May 11, 2000.
3. Dixon P. A list of some care plan considerations for integrated dementia care [Dementiacare Web site]. May 1, 1998. Available at www.dementiacare.org.   Accessed on May 11, 2000.