Delirium and dementia Flashcards
what is the most common affective disorder of old age
depression
what is depression often confused with?**
why?
dementia there is (can be) a cognitive decline that is related to apathy
are changes in cog ability, excess forgetfulness or modd swings a normal part of aging?
no It may be treatable mental condition.
what can cause changes in mental status**
• Changes in mental status may be related to alt in diet and fluid electrolyte imbalance, fever, low oxygen levels assoc w cardio and pulm diseases
when does depression often occur**
• Depression in o adults is often following major illness or loss and or r/t chronic pain or illness. May be secondary to med interaction or an undiagnosed condition
signs of depression**
• Signs: sleep disturbances, feelings of guilt or worthlessness, appetitie disturbances, restlessness, impaired attention span, dec memory or concentration, fatigue, sadness, suicidal ideation
reasons that depression and mental status should be assessed and monitored?
how would you do this?
-inc risk of suicide in caucasian men and men over 90
MMSE and geriatric depression scale
what should you do if pt has depression and a physica illness
• if pt has medical illness + depression the depression mustn’t be overlooked as it can impede recovery
why is depression often not treated?
is it responsive?
• Depression is often untreated d/t it not being identified but it is very responsive to Tx.
Tx of depression that is mild
May involve Tx of the underlying conditions causing the depression
• Mild depression Tx: exercise, bright lighting, inc interaction, cog therapy, reminiscence therapy
• Major depression:antidepressants, short term psychotherapy (esp in combination) are effective for o adults
Tx of major depression
tx of life threatening depression
• Major depression:antidepressants, short term cpsychotherapy (esp in combination) are effective for o adults
if life threatening use electroconvulsive therapy
meds for depression and what to watch for
• New meds can work well eg tricyclic antidepressants. Meds w anticholinergic, cardiac, orthostatic effects etc and any interactions should be used w care d/t falls and hypotensive events
how log can it take for symptoms to diminish (depression)
what should nurse do?
• May take 4-6 weeks for symptoms to diminish. Nurses should offer support during this time
which habits in older adults may influence/be influenced by depression
concerns with this
alcohol and drug abuse
• may be r/t depression
• inc incidence in o aduts. They often deny it and it remains hidden.
• alcohol abuse is v dangerous in o adults d/t age related changes in renal and liver fx as well as high risk of interactions w prescription meds
delirium aka
what is it and when does it often occur
• often termed acute confusional state
common and life threatening complication for the hospitalized older adult and most freq complication of hospitalization
delirium starts with ______ and progresses to _______
• starts w confusion and progresses to disorientation
is delirium treatable and preventable
often preventable
usually treatable
how is delirium broken down
hypoalert-hypoactive
hyperalert-hyperactive
-mixed hypo hyper
which types of delirium are hardest to Dx and which is easier
- hyperalert/hyperactive pts may demand more attention from the nurse and are easier to Dx
- recognition of delirium in the mixed type may be difficult
- pts w hypoalert-hypoactive type of delirium have higher mortality rates and even poorer outcomes of care as the delirium is often not recog and treated
signs symp of delirium**
• signs/symp: pts may experience altered LOC ranging from stupor (hypoalert-hypoactive) to excess activity (hyperalert-hyperactive) or a combo of the two (mixed)
o thinking is disorganized, attention span is short. May have hallucinations, delusions, fear, anxiety, paranoia
o acute symptoms: agitiation, disorientation, fearfulness-should be reported immediately
what is delirium often mistaken for?**
what is helpful in differentiating them
• delirium is often mistaken for dementia-its good to know pts usual mental status and whether changes are abrupt (delirium) or long term (dementia)
DSM criteria for dementia
Disturbance of consciousness (reduced clarity of awareness) with reduced ability to focus, sustain, or shift attention
Change in cognition (memory, disorientation, language) or the development of a perceptual disturbance not better accounted for by pre-existing dementia
Disturbance develops over short time period and tends to fluctuate over course of day
non modifiable risk factors for delirium**
previous cog impairment
age
what does delirium often occur secondary to aka modifiable risk factors**
delirium occurs 2ary to many things including: o physical illness o med or alcohol toxicity o dehydration o fecal impaction o malnutrition o infection o head trauma o lack of environmental cues o sensory deprivation or overload o fluid and electrolyte disorders
Her notes • Dementia • Polypharmacy • Fever/infections: UTI, Sepsis • Medical illness • Electrolyte imbalances • Renal disease • Hypoxia • Sx (cardiac, AAA (aortic abd aneurysm) • Alcohol abuse or withdrawal • Look for meds w CNS effects • Institutionalization
why is delirium a medical emergency
• d/t acute and unexpected onset of symp. It is a harbinger of acute medical illness. and unknown cause
delirium is a medical emergency
• if delirium isn’t recognized or treated it can result in permanent irreversible brain damage or death
-it can inc the risk of falls
course of delirium**
• course=acute onset, hypoalert-hypoactive, mixed, hyperalert-hyperactive
how long does delirium usually last (duration)**
- duration=1 day to 1 month
* if underlying problem is treted then the pt often returns to normal within a few days
Best Tx of delirium is ___
how do you do this
if you wait too long what is the next best Tx
- best Tx is prevention: therapeutic activities for cog impairment, early mobilization, controlling pain, minimizing use of psychoactive drugs, preventing sleep deprivation, enhancing communication methods eg glasses, hearing aids, maint 02 levels and fluid lyte balance
- if it occurs then the best Tx is treating the underlying conditions
if pt has delirium how will they be supported in hospital
-Tx of underlying conditions
• nonessential meds are often discontinued
• nutritional and fluid intake is supervised and monitored
• quiet calm env is best. Family can come and touch/talk to pt. Have familiar environmental cues
• ongoing mental status assessments w prior mental status as baseline are good
• if underlying problem is treted then the pt often returns to normal within a few days
how are AD and delirium different in terms of orientation and memory*
delirium:
fluctuates (this is generally true for all issues eg personality, psychomotor activity)
-impaired recent and remote memory t lucidity
-complete disorientation to AOx3 or lucidity
AD
the basic premise is that it is progressive. recent memory is lost first
dementia onset and progression
o there are cognitive, functional and behavioural changes and eventually the erson cant fx
o symptoms have subtle, slow onset (insidious)
type of dementia
o most common types are alzheimers disease (AD) 63% and vascular or multi infarct dementia 20%. Other non alzheimers dementias include parkinsons, AIDS-relatd dementia, Pick’s disease
symptoms of dementia from slides
Symptoms • Wandering • Aggression • Behave changes • Personality changes • Motor coordination change • Impaired cog skills (Lang, logical thinking, ability to learn)
how young can alzheimers occur
o can occur as young as 40 but is more common after 65. Not normal part of aging
two types of AD
what inc your risk of the second one
o classified by two types: familial or early onset and sporadic or late onset AD
o if pt have at least one other family member w AD then theres a familial component. 7% of AD is familial
risk factors of AD
o biggest risk factor is age. Environmental, inflm, dietary factors may inc. It is a combo of genetics, neurotrans changes, vascular abn, stress hormones, circadian changes, head trauma, presence f seizure disorders
patho of AD
o neurofibrillary tangles and neuritic plaques.
o Damage is mostly in cerebral cortex and decreases brain size
o Cells which use acetylcholine are primarily affected
o 2 key issues studied by scientists: whether a gene might influence a persons overall risk of dev the disease and whether a gene might influence some particular aspect of a persons risk eg age of onset
clinical mnfts of AD
o Early: forgetfulness, subtle memory loss. May have small difficulties in work or social activities but have adequate cog fx to compensate and fx independently.
o Forgetfulness may=losing ability to remember familiar faces etc including becoming lost in familiar environment
o Repeat the same stories
o Reasoning w them and using reality orientation doesn’t help and only inc their anxiety without inc in fx
o Word finding and conversations are diff
o Lose ability to think abstractly
o Impulsive
o Difficulty w everyday tasks like handling appliances and money
o Personality changes are also evident: depressed, suspicious, paranoid, hostile, combative
o Progression of the disease intensifies symp: will speak in nonsense, agitiation and phys activity inc, may wander at night. Assistance will eventually be nec for all ADLs as dysphagia and incontinence dev
what causes deat w AD
o Terminal stage: death is d/t complications eg pneumonia and malnutrition
how can you get definitive dx of alzheimers dementia
autopsy
how is AD Dx in gneral
by exclusion
o Most imp goal is to rule out other cases of dementia or reversible causes of confusion eg other types of dementia, delirium, depression substance abuse, med problems
o AD is a Dx of exclusion. A Dx of AD is made when the medical hx, physical exam and lab tests have excluded all known causes of other dementias
what types of diagnostics are used?
what types of imaging and why?
what other tests?
Hx, PmHx, med hx
o Diagnostics: CBC, chemistry profile, vitamin B12, thyroid hormone levels, EEG, CT, MRI, exam of CSF
o MMSE for screening
o CT and MRI are used to exclude hematoma, tumour, stroke, atrophy, normal pressure hydrocephalus but aren’t reliable in making a definitive Dx
which conditions can cause cog impairment that could be mistaken for AD
o Infections, physiologic disturbances eg hypothyroidism, Parkinson, vitamin B12 deficiency can cause cog impairment that may be misdiagnosed as AD
o Depression can closely mimic early stage AD and coexist in many pts
medical mgmt of AD
aims to-
cure?
o Primary goal is mgmt of cognitive and behavioural symptoms
o No cure, cant slow progression of disease
nurses role in AD care
o Nurses recognize dementia by assessing for signs during the admission assessment
o Interventions aim to promote pt fx and independence
o Want to promote phys safety, independence ins self-care activities, dec anxiety and agitation, improving communication, providing for socialization and intimacy, promoting adequate nutrition, balance activity and rest, supporting and educating caregivers
what is sundowning
sundown (exp inc confusion at night
what is catastrophic rxn
what can you do?
o Excitement and noise may result in upsetting the pt and catastrophic reaction (overreaction to excess stimulation). Pt may respond w screaming, crying etc as they have no other way of expressing themselves. If this happens be calm and unhurried. If nec postpone the event. May help to move pt to familiar env, distract etc
should family visit for long periods of time
brief
max 2 people
how does AD affect the family
Supporting home and community care
o Emotional burden on caregivers is huge
o Family members may cling to hope that the Dx is incorrect and the pt will improve with inc effort
o There are many diff decisions eg when to stop pt from driving or taking over the pts finances
o Family often misinterprets aggression from pt as the family feels unappreciated
o They may feel guilt, nervous, worry->caregiver fatigue, depression and family dysfx
o Respite care is an option for caregivers to get away while someone takes care of the person
do you want an exciting env for AD pts
no
calm predicatable env w minimal stimuli
which neurotransmitter is responsible for transmission of impulses in PNS
acetylcholine (Ach)
which type of drugs are used to treat AD
cholinergic drugs
cholinergic drug fx
o Mimic the effects of ACH
o Can indirectly or directly stim the cholinergic receptors. Indirectly acting cholinergic agonists act by stim postsynaptic nerve cell (neuronal) release of Ach at receptor site, allowing Ach to bind to and stim the receptor. This is accomplished by inhibiting the action of acetylcholinesterase inhibitor
how are cholinergic drugs useful for AD pt
o In Tx of AD, cholinergic drugs inc the conc of Ach in the brain and as a result improve cholinergic fx
Inc Ach levels inc or maint memory and learning capabilities
All are indirect-acting anticholinergic drugs (they inhibit cholinesterase)
Therapeutic efficacy is often limited but they can enhance pts mental status enough to make noticeable but maybe temporary improvement in quality f life and therefore for caregivers too.
Pt response to these drugs is variable
wasnt really discussed in class but worst case scenario with cholinergics is
antidote?
o Most severe consequence of an OD is a cholinergic crisis. Symp may include: circulatory collapse, HoTN, bloody diarrhea, shock, cardiac arrest (these are the more serious ones)
o Use ATROPINE a cholinergic antagonist to reverse symps
names of the acetylcholinesterase inhibitors
exeloexn
aricept
reminyl
exelon aka what oes it act on good for? advantage? adverse e?
Rivastigmine hydrogen tartrate (Exelon)
o Indirect acting cholinergic Inhibits cholinesterase
o Indicated for mild to moderate AD
o One advantage in comparison to others is that dosage adjustments aren’t needed or recommended for pts w kidney or liver impairment
o Adverse e: NVD, dizziness, headache, anorexia
o Oral
in general cholinergics for Ad seem to be indicated for mild to moderate AD, they cause Gi upset and dizziness, and they are oral
w
reminyl
Galantamine hydrobromide (Reminyl)
o Indirect acting cholinergic. Inhibits cholinesterase
o Indicated for mild to moderate AD
o Not good for pts w severe renal or hepatic impairment
o Adverse: syncope, nausea, dizziness, vomiting, anorexia
o Can alter cardiac conduction
o Oral
main problem with reminyl
can alter cardiac conduction
aricept
Donepezil hydrochloride (Aricept)
o Indirect acting acetylcholinesterase drug that works centrally in brain to inc Ach levels by preventing breakdown
o Used for mild to moderate AD
o Oral. Once daily
what to assess before giving cholinergics
seems to differ a bit with the drug:
vitals
mental status, mood, affect, changes in mental behaviour, depression, LOC, suicidal tendencies
reminyl, aricept=cardiac, liver, & kidney fx
-GI and Gu (can cause retention)
mnemonic DELIRIUMS for causative factors
D rugs* (new/withdrawal)
E nvironment/eyes/ears
L ow oxygen/hgb
I nfection
R etention (stool/urine)
I rritation (pain/anxiety)
U nder-hydrated/nourished
M etabolic
S troke/shock/subdural
since cholinergics generally cause dizziness what may occur
what should be done to prevent this
falls
have support for pt eg ambulatory aids
Confusion assessment method
if someone is having delirium what would they have to have fom this scale
both a and b
A Acute onset And Fluctuating course
B Inattention
and one of either c or d
C Disorganized
thinking
D Altered level of
consciousness
