BROAD CONCEPT BROAD CONCEPT COGNITIVE IMPAIRMENT COGNITIVE IMPAIRMENT DISORDERS: DISORDERS: DELIRIUM AND DEMENTIA DELIRIUM AND DEMENTIA
May 22, 2015
BROAD CONCEPTBROAD CONCEPTCOGNITIVE IMPAIRMENT COGNITIVE IMPAIRMENT
DISORDERS:DISORDERS:DELIRIUM AND DEMENTIADELIRIUM AND DEMENTIA
PATHO/DELIRIUMPATHO/DELIRIUM
• Cognitive Impairment• If treat early enough is reversible• Characterized by clouding of the
consciousness, inability to focus & maintain attention, & altered perception
DELIRUMDELIRUM
• Occurs in 10-40% of hospitalized clients, 30-40% of hospitalized client with AIDS, & up to 60% of nursing home residents who are 75 years old & older.
• 80% of hospitalized clients near death will develop delirium.
• Occurs suddenly.
• CNS(central nervous system) affected by many conditions e.g. anemia, ischemia, hypoglycemia, lack of Vitamin B, endocrine disorders, toxicity from alcohol or drugs, trauma, infections, etc.
• Physical restraints may contribute
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Behavior: poor impulse control, may be withdrawn or agitated
• Speech: dull or rapid & pressured
• Picking at clothing and/or the air
• Bizarre behavior at night/Sundowner’s
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Affect:
• Range from apathy to irritability
• Labile emotions
• Laughing or sad
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Cognition: disorganized thinking (rambling speech) & ↓ ability to maintain & shift attention
• Visual hallucinations /altered perception are common
• Thinking, memory, attention and perception are disturbed
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Interpersonal Relationships: Families are anxious & frightened
• Physical: Sleep disturbance and tremors.
• Safety: Keep the client safe!
INTERVENTIONS
• Eliminate cause of delirium
• Monitor LOC continually
• Reorient with each interaction – introduce self and call client by their name
• Use short, simple, concrete phrases
• Keep the room well lit
• Provide clocks and calendars
• Have client use assistive devices (hearing aids/glasses
• Clarify reality while justifying emotions/feelings
EVALUATE EVALUATE PHARMOCOLGPHARMOCOLGY
• Depends on cause of delirium– Treat underlying cause first
• Haloperidol (Haldol) 1-2mg IV over 1-3 min may control symptoms. May be given with lorazepam (Ativan) IM
EVALUATE EVALUATE PHARMACOLOGYPHARMACOLOGY
• If EPS develops, give diphenhydramine (Benadryl) 25-50mg
DEMENTIADEMENTIA
• Alzheimer disease (AD) is behind 60-70% of late-onset dementias. Affects 4.8 million Americans
• $200 billion in U.S. spent yearly
• Affect 50% of persons over age 85
• Women more than men
• 15-20% are inherited
• Course is 5-10 years
CULTURECULTURE
• Cultural Influences:• In U.S ↑ risk for AD in Latin Americans & African
Americans• Japanese, Italians, & those from Hong Kong have
a greater risk in Europe & Asia• ↑ lower educational and socioeconomic levels• ↑clients with previous head injuries• ↑ clients with relatives that have AD
ETIOLOGIESETIOLOGIES
• Video: www.nia.nih.gov/alzheimers/ADvideo
• Genetics – cause is unknown, focusing on beta-amyloid protein that accumulates into plaques
• Early onset (30 to 60 y/o) is rare (5%) and is related directly to the Alzheimer’s gene
ETIOLOGIESETIOLOGIES
• 1-Neurofibrillary tangles (twisted fibrils inside the neuron that disrupt cellular processes and eventually kill the cell)
• 2-Plaques (it is the quantity of plaques in relation to the person’s age that is significant) (a) widened sulci and narrowed gyri
AD
• AD affects:– Communication, metabolism, and repair
process of neurons in the brain
• Which causes:– Memory failure– Personality changes– Difficulty carrying out ADLs• There is a progressive decline
ADAD
• 4 stages
• Mild – lasts 2-4 years
• Moderate – longest stage, day care may be necessary
• Moderate to Severe AD – lasts 1-2 years, 24/7 care needed
• Late/End stage
Stage 1 (Mild AD)
• Mild – lasts 2-4 years:
• characterized by– Short-term memory loss– Uses memory aids such as lists and
routine– Aware of the problem– Depression is common– NOT diagnosable at this stage
Stage 2 (Moderate AD)• Stage 2 Moderate AD is characterized by:
– Progressive memory loss– Withdrawn from social activities– Decline in instrumental ADLs (money
management, cooking, driving)– DENIAL – fears “losing” his/her mind– Depression– Confabulation – Symptoms worsen with physical/emotional stress
Stage 3 (Moderate/Severe AD)
• Stage 3 Moderate to Severe AD is characterized by:– ADL losses: willingness to bathe, grooming,
choosing clothing, toileting, communication, reading/writing
– Loss of reasoning ability– Depression resolves as they become unaware of
loss– Difficulty communicating– Usually institutionalized or need care 24/7
Stage 4 (Late / End stage)
• Stage 4, late / end stage AD is characterized by:– Family recognition/self recognition disappears– Non-ambulatory– Forgets how to eat, swallow, chew, wt loss– Incontinent– 24/7 care required– Return to infantile reflexes and ultimately Death
• Death usually secondary to infection or choking
7 WARNING SIGNS of AD7 WARNING SIGNS of AD
• Asking the same questions over & over
• Repeating the same story, word for word, again & again
• Forgetting how to cook, or how to make repairs, or how to play cards – activities that were previously done with ease
• Losing one’s ability to pay bills or balance one’s checkbook
7 WARNING SIGNS of AD7 WARNING SIGNS of AD
• Getting lost in familiar surroundings
• Neglect to bathe, or wearing the same clothes over & over while insisting they are clean & are wearing dirty clothes
• Relying on someone else close to them to make decisions or answer questions that they used to handle
OTHER DISORDERSOTHER DISORDERS
• Pseudodementias - mimic dementia
• Causes:
• Drug toxicity
• Infections
• Metabolic disorders
• Nutritional deficiencies
• Depression- most common cause
EVALUATE EVALUATE PHARMOCOLOGYPHARMOCOLOGY
• DONAZEPIL (Aricept) 5mg P.O. daily @ bedtime. After 4-6 weeks↑ to 10mg
• Classification: cholinesterase inhibitor• Action: improves cholinergic function by
inhibiting acetylcholinesterase• Improves cognitive function• *Missed doses should be skipped and
regular schedule returned to the following day.
EVALUATE EVALUATE PHARMACOLOGYPHARMACOLOGY
• Rivastigmine (Exelon) 1.5 mg. twice a day with food, may ↑ by 1.5 mg. twice a day every 2 weeks if tolerated. Target dose 3 – 6 mg. twice a day. Max. dose 12 mg twice a day
• Classification: Cholinesterase Inhibitor
• Action: Treats mild to moderate AD
EVALUATE EVALUATE PHARMACOLOGYPHARMACOLOGY
• Galntamine (Reminyl) 4 mg. twice a day for at least 4 weeks, if tolerated may ↑ by 4 mg. twice a day every 4 weeks. Target dose 12 mg twice a day.
• Classification: Cholinesterase inhibitor
• Action: treat mild to moderate dementia
EVALUATE EVALUATE PHARMACOLOGY PHARMACOLOGY
SE: HA, diarrhea, nausea, sweating, bradycardia, & insomniaNSG: Taking after breakfast may lessen side effects, teach how family how to monitor pulse*Do not cure – only slows down the disease
EVALUATE EVALUATE PHARMACOLOGYPHARMACOLOGY
• memantine HCL (NAMENDA)
• Used in moderate to severe Alzheimer’s or with an acetylcholinesterase – less GI disturbance
• Side effects: dizziness, HA, confusion and constipation
MULTIDISCIPLINARY INTERVENTIONS
• Speech therapy
• Physical therapy
• Occupational therapy
• Social workers
• Pastoral counselors
• New hope is gene therapy – new nerve growth
ALTERNATIVE THERAPIESALTERNATIVE THERAPIES
• Antioxidants – found in green tea, grape seed extract, deepest color fruits & veggies
• Omega-3 Fish Oil – found in salmon, mackerel, sardines
• Phosphatidyl Serine – keeps nerve cells flexible
• Melatonin – for sleep• Estrogen – may be preventative in women
(not useful in existing dementia)
ALTERNATIVE THERAPIESALTERNATIVE THERAPIES
• Dehydroepiandrosterone (DHEA) – regulates mood
• S_adenosylmethionine (SAMe) – improves cell membrane flexibility, caution in people with cardiac history
• Lecithin – found in soybeans & eggs• Ginkgo Biloba –increase risk for bleeding
ALTERNATIVE THERAPIESALTERNATIVE THERAPIES
• Music– What type of music would be appropriate?
• Touch– How should a client with dementia
touched? What approach should the nurse take?
• Animal-Assisted– Assess for fears first, if possible
• Behavior: Wandering, unable to do complex tasks, frightened by their confusion, attempt to cover up symptoms, need assistance dressing
• ↑ appetite & food intake – no ↑ in weight
• Repetitive behaviors – lip smacking, pacing
• Sundown Syndrome – disoriented at days’ end. Orientated in day.
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Affect:
• Mild stage: anxiety & depression occur
• Moderate stage: ↑ lability of emotions (rage, irritability)
• Severe stage: person becomes unresponsive to environment
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Cognition: ↓ in concentration, ↑ distractibility, absent-mindedness, unable to make judgments
• Language skills begin to deteriorate
• Difficulty word-finding
• In mod AD – memory loss (recent & remote)
• Confabulation: filling in gaps with imaginary information
• Misidentification syndrome – familiar people are unfamiliar
• Aphasia – unable to understand language
• Agraphia – unable to read or write
• Agnosia – unable to recognize familiar people or situations
• Alexia – unable to tell what to do with a frying pan, toothbrush, telephone
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENT - COGNITIONASSESSMENT - COGNITION
SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT
• Perception: visual hallucinations most common– What would our intervention be?
HIGHER NEEDSHIGHER NEEDS
• Can you think of some problems with clients & AD as they try to fulfill their higher needs? Which ones would be affected?– What would some interventions be to help
address these higher needs?
NURSING CARENURSING CARE
• Safety is first priority for delirium & dementia– What are some interventions we can do
address the safety issues for clients with delirium and dementia?
• Find local resources such as _________
NURSING CARENURSING CARE
• What are some interventions that you can think of for someone suffering from AD?
• How would you assist families?
Diagnostic Tools
• No definitive test
• PET
• MRI
• SCT and PET
• MSE