Delirium, dementia, and depression Flashcards

Question

Nursing care to prevent delirium

Answer 1

* Orientation and therapeutic activities * Early mobilization * Minimize use of psychoactive drugs * Prevent sleep deprivation * Adaptive methods (eye glasses and hearing aids) * Early treatment of volume depletion

Answer 2

``` Dementia • Multiple underlying etiologies • Chronic and slowly progressive • Non-reversible • Cannot be diagnosed in a patient with delirium ``` ``` Delirium • Multiple underlying etiologies • Acute and rapidly progressive • Usually reversible • May be diagnosed in a patient with dementia • Medical emergency ```

Answer 3

1. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains • such as complex attention, executive function, learning, memory, language, perceptual-motor or social cognition This evidence should consist of: • Concern of the individual, a knowledgeable informant (such as a friend or family member), or the clinician that there’s been a significant decline in cognitive function; and • substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing. Of if neuropsychological testing isn’t available, another type of qualified assessment. 2. The cognitive deficits interfere with independence in everyday activities (e.g., at a minimum, requiring assistance with complex instrumental activities of daily living, such as paying bills or managing medications). 3. The cognitive deficits don’t occur exclusively in context of a delirium, and are not better explained by another mental disorder.

Answer 4

* Modest increase in processing time * Increased emphasis on relevance * Increased distractibility

Answer 5

* Increasing Age * Family history * Smoking * High cholesterol * Diabetes * Untreated depression * Alcohol

Answer 6

* Memory loss affecting day-to-day abilities * Difficulty performing familiar tasks * Problems with language * Disorientation in time and * Impaired judgment * Problems with abstract thinking * Misplacing things * Changes in mood and behaviour * Changes in personality * Loss of initiative

Answer 7

* Alzheimer dementia (AD) > 60% * Vascular dementia (VaD) - 3-4 months post stroke - More abrupt step wise deterioration • Parkinson dementia - Motor aspects • Frontotemporal dementia (FTD) - More disinhibited • Lewy body dementia (LBD) - fluctuations throughout day - prone to hallunications • Mixed dementia; dementia related to HIV or alcohol

Answer 8

• Different staging systems exist (e. g. Reisberg Functional Assessment Staging (FAST) Scale out of 16) 3 stage model • Mild - forgetfulness and misplacing things. Word finding difficulty. Person can still function rather independently and requires little care assistance. May require help with IADLs (especially more complex). Judgment can be impaired • Moderate - increased confusion, greater memory loss, and worsening judgment. May not recall all personal info. May need help with some ADLs (bathing, dressing, grooming). May notice changes in sleep patterns, as well as in their personality and behaviour • Severe – Individuals often lose the ability to communicate fluently or engage in conversation, though they may still be able to speak. Decline in physical capabilities, including difficulty eating and swallowing, inability to control bladder and bowel movement, and difficulty walking 7-9 years.

Answer 9

Commonly used tools: 1. Mini-Cog + Clock drawing 2. Mini-Mental State Examination (MMSE) 3. Montreal Cognitive Assessment (MoCA)

Answer 10

* Standardized and validated measure * Improves communication with interprofessional team; all members understand meaning/implication * Assists clinicians in characterizing the population they serve * Can document change in clinical presentation over time * Solve clinical problems and plan appropriate interventions * Aid in teaching clinical assessments to colleagues and students

Answer 11

- Want to give them the time/space to succeed, want them to do the best they can - Once they are labelled, it follows them throughout the rest of their healthcare journey; may be treated differently - These terms can have long term consequences - Validated tool; research done on particular wording of questions and style of test How screening tools are completed • Privacy; ensure caregiver doesn't interfere with test • Comfort (pain, toileting) • Distractions; aids for impairment, etc. • Therapeutic relationship • Sensory impairments • Language Responding to patient • Are they agitated, angry, lethargic, confused?

Answer 12

* Consists of a memory task that involves recall of three words and an evaluation of a clock drawing task * Less affected by subject ethnicity, language, and education (vs. MMSE), and can detect a variety of different dementias Step 1: Three Word Registration (not scored) •“Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The words are [select a list of words]. Please say them for me now.” • If the person is unable to repeat the words after three attempts, move on to Step 2 (clock drawing). Step 2: Clock drawing • Draw a circle so it looks like a clock. • “Put the numbers on clock. Make the clock say “10 minutes past 11” or 11:10” Step 3: Three word recall and scoring • Ask the person to recall the three words you stated in Step 1. • Say: “What were the three words I asked you to remember?” • Record the word list version number and the person’s answers - Need to score well on both sections to be classified as non-demented - 3/5 or above scores non demented

Answer 13

* Most widely used mental status exam * Test is scored out of 30 * Screening test – not diagnostic * Classifies no cognitive impairment, moderate cognitive impairment, or severe cognitive impairment * Does not assess for executive functioning * Screens for memory, language and perception * Available in many languages (interpreter) * Should adjust for education level; different versions based on education level Groups - no cognitive impairment - mild to moderate cognitive impairment - severe cognitive impairment - Not just in or out classification; grades it

Answer 14

* The MoCA's advantages include its reliability as a screening test for Alzheimer's disease * It measures an important component of dementia that's not measured by the MMSE, namely executive function. * A disadvantage of the MoCA is that it takes a little longer than the MMSE to administer * It should be paired with multiple other screenings and tests to accurately identify and diagnose dementia

Answer 15

- Categories of behaviour that go along with dementia 1. Amnesia – loss of memory; lead to easy susceptible to information overload 2. Aphasia – loss of language; both types (receptive: jumbled input or expressive: jumbled output); hard to communicate, leads to social withdrawal, reversion to primary language 3. Agnosia – loss of recognition 4. Apraxia – loss of purposeful movement; lose how to plan and sequence movement (muscle memory) 5. Altered perception – loss of visual acuity; also refers to other sensory losses as well 6. Apathy – loss of initiation: “she doesn’t want to do anything”; any initiation (not just physical movement like apraxia); any participation 7. Anosognosia – no knowledge of disease; difficult for advanced planning (MAID, etc) if they don't remember the disease and their previous choices

Answer 16

* Difficulty recognizing what something is (through any sensory modality) * Will be unable to recognize or name what it is * Occurs despite intact sensory modalities Examples: • Cannot recognize who people are (lose recognition in reverse order of having met them, i.e. grandkids first) • Thinking of self as much younger and not recognizing self in mirror • Thinking that people are imposters • Inappropriate use of objects • Defensive reactions when someone else tries to use an object on them • Impaired auditory recognition

Answer 17

• Misinterpretation of sensory information. • Depth perception is most often affected. • Also see visual distortions (i.e. warped) - Because their perception of environment changes, how they move in the environment changes Examples: • Not able to determine how deep water is (may fear bathing in tub) • Dark thresholds or tiles on floor look like holes (person avoids the holes) • Clothing on a chair, coatrack, etc. looks like a person • People on the TV are in the room (responds to TV) • Having a hard time positioning themselves in a chair (not know where edge or middle is) • Bumping into objects when mobilizing • Stooped pose and gazing downwards when mobilizing (shuts out overwhelming sensory info)

Answer 18

* Over 90% of dementia patients experience responsive behaviours, also known as neuropsychiatric symptoms or behavioural and psychological symptoms of dementia (BPSD), * Including physical or verbal aggression with psychosis (auditory or visual; false beliefs; delusion; hallucinations) • They are responding to something and can’t articulate what it is - Unmet need, it's our job to find out what they're responding to - Number one priority is SAFETY * May poses risk of harm to the patient and those caring for them, sometimes can be harmless * Providing care safely for the patient with BPSD is very challenging in all settings including acute care * Refusing care, refusing meds, refusing to bath

Answer 19

Activator/Antecedent • What happened just before the behaviour? ``` Behaviour • What is this person doing? • Where is this happening? • Who is present? • When is this happening? ``` Consequences • What happened just after the behaviour?

Answer 20

• Think: What is causing their behaviour? • Apply person-centred care principles (REAP): Relationship Environment Abilities Personhood • Medications are modestly effective at best – but are associated with adverse events like falls, death • Non pharmacological options are first line treatments; with the aims of mitigating the activator • Pleasant events (anything that adds pleasure to their day) can be a distractor or redirector • Disturbed versus disturbing behaviours (harmless but disrupting people around them) - When communicating connect with the emotion, if applicable

Answer 21

- Common of someone who has dementia - Throughout the day, as the sun is setting their behaviours get worse - As the stresses of the day build up; later part of the day they can no longer constrain themselves - May need to take into considerations when to provide care for the individual * Symptom of Alzheimer's disease and other forms of dementia. * It's also known as “late-day confusion.” * Their confusion and agitation may get worse in the late afternoon and evening. * In comparison, their symptoms may be less pronounced earlier in the day

Answer 22

* Follow a set routine; sense of home, sense of comfort * Don't rush and provide extra time for communication and tasks * Keep instructions simple * Reduce distractions; don't overwhelm them * Don't argue or try to correct patient * Distract patient by changing the subject or offering a snack * Be flexible; come back later if not a good time * Cautions the use of prn medication for agitation; behavioural interventions work best (non-pharm options first)

Answer 23

* Musical memory is considered to be partly independent from other memory systems * Musical memory is relatively preserved in Alzheimer’s disease and other dementias.

Answer 24

* Depression is one of the most misdiagnosed, under- diagnosed and under-rated illnesses experienced by older persons. * Mood disorder characterizes by a pervasive low mood or a loss of interest in activities and difficulty with: * Sleep, appetite, energy, concentration, worthlessness of guilt, motor slowing (thinking slow, moving slow), suicidal ideation * Lasting for 2 weeks or more that affects daily life

Answer 25

``` Physical factors • Chronic disease • Acute myocardial infarction • Organic brain disease • Endocrine/metabolic diseases • Malignancy • Chronic pain and disability ``` ``` Psychological factors • Social isolation • Change in financial circumstances • Being a caregiver • Change in role and loss of social status • Bereavement and loss • Difficulty adapting to illness/pain/disability • History of depression • Being institutionalized (transitions) ```

Answer 26

• Second leading cause of disability worldwide; treatable • Not a normal part of aging • Endorse physical complains but deny sadness • Highest rate of suicides – older white males • Worsens other illnesses like cardiac disease, cognitive decline - Being depressed accelerates cognitive decline through social isolation

Answer 27

• Different screening tools exist • Some are most suited towards particular patient populations - Geriatric Depression Scale; Cornell Scale for Depression • If depression is likely, then exploring suicidal ideation is important • Important to determine suicide risk and intervene - "Have you thought of doing anything to hurt yourself?" - If they respond yes; verify if they have a plan; somebody who has a plan is at a much higher risk; urgency for triage - OAs are at the higher risk fo completion of suicide on the first attempt after being diagnosed with depression

Answer 28

``` Dementia • Onset; vague cognitive symptoms first • Course; slow and progressive • Variation; worse at night • Cognitive symptoms (subjective); does not complain, covers up, family/friends notice ``` Depression • Onset; more defined, depressive symptoms first • Course; more rapid and unequal • Variation; dinural variation, worst in the AM, early AM wakening • Cognitive symptoms (subjective); stressed, complains more, lack of energy

Answer 29

▪ Only 10% receive treatment, untreated it can last years; depression is treatable ▪ Medication ▪ Antidepressants ▪ Medication to treat associated agitation and/or psychosis ▪ Supportive Care Strategies ▪ ECT – most effective treatment (electro compulsive therapy) - 80% can have some alleviation of their depressive symptoms

Answer 30

Support the person by: ▪ Understanding that behaviour is due to an illness, and recovery is more complicated than just “pulling up your socks”, or “trying harder” ▪ Offering reassurance: don’t push the person beyond what the person is capable of doing at the time ▪ Listening

Answer 31

* DDD are 3 distinct syndromes that are very common in older adults * Can all exist simultaneously in the same person, and can confer increased risk in the other * Diagnosis is key to treatment Common features of DDD: • Confusion • Irritability • Disrupted sleep Differentiating features: • Time course • Causes are different • Interventions

Answer 32

- With higher risk of mortality, longer stay, and increased functional decline - Under detected in ED - Discharge from ED due to inability to provide accurate reasons of why they are at the ED or creating patient safety hazards by being aggressive.

Answer 33

Interaction of multiple factors: Precipitating factors - Pain - Urinary retention - Constipation, - Dehydration - Polypharmacy Environmental factors - Chaos - Unfamiliar and threatening env. - Temperature - Soiled brief - Causing sensory overload

Answer 34

``` Measures 4 cognitive elements 1.Acute onset and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness ● Delirium = 1 + 2 + 3 or 4 ```

Answer 35

Combination of factors that make the individual more vulnerable to delirium - Predisposing factors and precipitating factors - Cause acute mental disturbances

Answer 36

- Infection, - Head trauma, - Electrolyte disturbance, - Mycocardial infarction/acute coronary syndrome, - Hypoxia - Hypoglycemia - Stroke - Renal insufficiency - Liver failure

Answer 37

- Effective communication - Avoid gestures with hands when talking or rapid movements and touching. - Hearing and visual aids for sensory impairments - Social support from family and friends - Reducing noise in the environment, visible clocks, calendars, reorienting patients, low lighting - Avoid physical restraints

Answer 38

``` A: analgesia B: bladder-urine retention C: Constipation D: dehydration E: environment F: pharmacy (medications) ```

Answer 39

- Reorient patient frequently - Arrange for family members to stay with patient - Address patient face-to-face - Talk clearly, slowly, repetitively - Keep your hands in sight when possible, avoiding gestures or rapid movements that may be misinterpretated as aggressive - Use interpretators if difficulty with comprehension of language - Optimize lighting in room - Replace hearing aids - Put glasses on - Put dentures in - Check if the patient is hungry - Avoid room/location changes as much as possible

Answer 40

CIND- cognitive impairment not dementia. Sits somewhere between normal aging and dementia. Uses for cognitive assessment: - Screening for cognitive impairment - Differential diagnosis of cause - Rating severity of disorder or monitoring disease progression

Answer 41

- 30 pt assessment tool - Common method to screen for progression of dementia and delirium - Variation due to type of questions asked - Type of questions asked limit the ability to detect non-Alzheimer's dementia such as post-stroke cognitive impairment, frontotemporal or subcortical dementias in their earlier phases. - Standardized mini-mental state examination (SMMSE) has been introduced to reduce inter-rater variability in scores - Incorporates the same questions but with clear guidance on admin, scoring and time allowed for each component

Answer 42

- Brief 10-scale item test to screen impairments - Requires intact short and long term memory, attention and orientation. - Quick screen option that may detect changes in cognition associated with the post-operative development of delirium

Answer 43

- Orientation questions and a three item recall task derived from MMSE

Answer 44

- Six items, including one memory, two calculation and three orientation questions. - Less suitable for busy clinical settings

Answer 45

- Screen for visuospatial, constructional praxis and frontal/executive impairment - Pt is asked to draw a circle and then put numbers on it as if a clock face. - Inability to space numbers around clock- could be due to visuo-spacial impairment, neglect or a planning deficit - Then pts asked to add hands to a specific time (eg 10 past 11) - Testing pt’s capacity to commute the min hand should point at the 2 not the 10 - Also tests both sides of visual fields

Answer 46

- Ads a 3 word recall test to the CDT, improving memory testing - Classified as having cognitive impairment if unable to recall any of the three words or if only recalling 1-2 words and drawing an abnormal clock - Not a numerical scale but just declares impaired cognition is either present or not. - So cannot use to monitor disease progression

Answer 47

- Ability to focus on a task

Answer 48

Four subtypes: - Episodic- related to personal experiences - Semantic - interpersonal facts - Procedural memory - performing actions - Working memory - capacity to briefly ‘hold it in your head’ - Orientation questions test both short term memory and attention

Answer 49

- Presence of a language disturbance suggests a problem with the dominant hemisphere

Answer 50

- Disturbance could be due to a lesion in either hemisphere

Answer 51

- Rare in community - increases within hospital admission - Elderly patients with delirium is highest in ICU > post-operative

Answer 52

- Drug toxicity, inflammation and acute stress contribute to disruption of neurotransmission - Results in the development of delirium - Pathological process associated with delirium can cause a neuronal injury which causes cognitive impairment

Answer 53

Dementia - Delirium is potentially preventable and treatable, but major barriers, including under-recognition of the syndrome and poor understanding of the underlying pathophysiology - Current evidence suggests that disruption of neurotransmission, inflammation or acute stress responses might contribute markedly to the development of delirium - Delirium is not always transient and reversible, and it can result in long-term cognitive changes

Answer 54

- Hypoactive- lethargy and sedation, respond slowly to questioning (occurs most frequently in elderly) - Usually overlooked/ misdiagnosed as depression/dementia in elderly patients - hyper- active - restlessness, agitation - Mixed - Postoperative delirium can develop on the first or second postoperative day. Delirium can be difficult to recognize in the ICU, as standard cognitive tests of attention often cannot be used in this setting because patients are intubated and cannot answer questions verbally

Answer 55

- dementia, - male, - renal disease - intercurrent illness - multiple co-morbidities - >65 years old - history of delirium, stroke or falls - sensory impairment - immobilization (restraints or catheter)

Answer 56

- medications - infections - acute neurological diseases - pain - sleep deprivation - emotional distress - surgery - environment (admission to ICU)

Answer 57

- Increased nursing time per patient - Higher per day hospital costs - Increased length of hospital stay

Answer 58

- Keep depression in mind when evaluating frequent flyers, vague historical with multiple complains, OA with weakness, just the the same as they usually are

Answer 59

- Three questions to screen for depression 1) Do you often feel sad or depressed 2) Do you often feel helpless 3) Do you often feel down or blue