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NUR360 > Delirium, Dementia, Depression > Flashcards

Delirium, Dementia, Depression Flashcards

1
Q

Delirium

A

A serious acute neuropsychiatric syndrome characterized by inattention and acute cognitive dysfunction

  • a symptom of an underlying condition
  • life threatening
  • 30-40% preventable and reversable
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2
Q

Why is diagnosis of delirium important?

A

May be the ONLY SIGN of significant medical illness such as:

  • pneumonia
  • sepsis
  • abdominal infection
  • intra-cerebral event
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3
Q

Consequences of Delirium

A
  • functional impairment
  • prolonged hospitalization
  • institutionalization
  • psychological stress
  • death
  • full recovery
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4
Q

Risk Factors for Delirium

A

Non-modifiable

  • dementia
  • multiple comorbidities
  • advancing age >65
  • hx of delirium, stroke, neuro disease, falls or gait disorder
  • chronic renal or hepatic disease

Potentially modifiable

  • sensory impairment
  • medications
  • acute neurological diseases
  • sustained sleep deprivation
  • environment
  • pain
  • emotional distress
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5
Q

Causes of Delirium

A

Multifactorial, almost any medical illness, intoxication or medication can cause delirium

I WATCH DEATH
infection, withdrawal, acute metabolic (sedatives), toxins, CNS pathology, hypoxia

deficiencies (b12), endocrine (thyroid), acute vascular (shock), trauma, heavy metals

DELIRIUM
dementia, electrolyte, lung liver heart kidney brain, infection, Rx, injury, unfamiliar environment, metabolic

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6
Q

Clinical Presentations of Delirium

A

a. Hyperactive “agitated”
b. Hypoactive “sleepy, difficult to rouse”
c. Mixed

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7
Q

Key Clinical Features of Delirium (3 core + 5)

A
  1. inattention
  2. disorganized thinking
  3. altered LOC
  4. cognitive deficits
  5. perceptual disturbances
  6. psychomotor disturbances
  7. altered sleep cycle
  8. emotional states (rapid change)
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8
Q

Delirium Superimposed on Dementia (DSD)

A

Occurs when an individual with a pre-existing dementia develops delirium

assumed to be worsening dementia

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9
Q

Delirium Assessment

A
  1. hx or dx of dementia or chronic cognitive decline
  2. hx of cognitive impairment
  3. gather details
    a. symptoms/behaviours - types, frequency, course
    b. onset
    c. duration
  4. assessment q 8-12 hrs
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10
Q

Confusion Assessment Method (CAM)

A

C1 and C2 both present + C3 or C4

Criteria 1: acute onsent and fluctuating course

Criteria 2: inattention

Criteria 3: disorganized thinking

Criteria 4: altered LOC

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11
Q

Warning words during assessment

A 
"not feeling/acting right"
"weak"
"just not himself/herself
"vague complaints"
"pleasantly confused"
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12
Q

Q 8-12 Hr Assessment of Delirium

A
  1. LOC
  2. Attention
  3. Orientation
  4. Thought process
  5. Memory
  6. Perception (hallucinations/illusions)
  7. Sleep/wake cycle
  8. Affect

Behaviours:

  1. Motor
  2. Verbal or physical aggression
  3. Resistance to care
  4. Wandering/exit seeking
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13
Q

Delirium Treatment

A
  1. Treat cause
    INVESTIGATE: collateral help, review EMR, routine bw, ECG, Xrays/CT, urine analysis
  2. Non-pharmacologic
    therapeutic communication, reduce internal/external stressors, involve family, diversion activities
  3. Pharmacologic
    medication review, treat agitation?
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14
Q

Prevention of Delirium

A

(HELP program)
Consider:

a. continuation of care
b. sleep deprivation
c. immobility
d. sensory impairment
e. dehydration
f. cognitive impairment

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15
Q

Nursing Care to Prevent Delirium

A
  • orientation and therapeutic activities
  • early mobilization
  • minimize use of psychoactive drugs
  • prevent sleep deprivation
  • adaptive methods (glasses and hearing aids)
  • early tx of volume depletion
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16
Q

Dementia (DSM5)

A
  1. significant cognitive decline in one or more cognitive domains
    (attention, executive functioning, learning, memory, language, perceptual-motor, social cognition)
    a. concern from informant
    b. neuropsychological testing
  2. interference with independence in everyday activities
  3. don’t occur in context of delirium and not explained by other mental disorders

cannot be diagnosed in patient with delirium

17
Q

Normal age related changes in memory

A
  • modest increase in processing time
  • increase emphasis on relevance
  • increased distractibility
18
Q

Risk Factors of Dementia

A
  • increasing age
  • family hx
  • smoking
  • high cholesterol
  • diabetes
  • untreated depression
  • alcohol
19
Q

10 Warning Signs of Dementia

A
  1. memory loss affecting day to day
  2. difficulty performing familiar tasks
  3. problems with language
  4. disorientation in time
  5. impaired judgment
  6. problems with abstract thinking
  7. misplacing things
  8. changes in mood and behaviour
  9. changes in personality
  10. loss of initiative
20
Q

Types of Dementia

A

a. Alzheimer dementia (gradual onset)
b. Vascular dementia (often after stroke)
c. Parkinson dementia (motor)
d. Frontotemporal dementia (judgment and control)
e. Lewy body dementia (hallucinations)
f. Mixed dementia (or related to HIV or alcohol)

21
Q

Stages of Dementia

A

Mild: forgetfulness and misplacing things, word finding difficulty, impaired judgment

Moderate: increased confusion, greater memory loss and worsening judgment, changes in personality and behaviour, help with ADLs

Severe: unable to communicate meaningfully, decline in physical capabilities, incontinence, immobility

22
Q

Screening Tools for Dementia

A
  1. Mini-cog + clock drawing
    - 3 word recall and clock drawing
    - step 1 words, step 2 clock, step 3 recall words
  2. Mini-Mental State Examination (MMSE)
    - out of 30
    - screening not diagnostic
    - memory, language and perception but not executive functioning
  3. Montreal Cognitive Assessment (MoCA)
    - reliable screening for Alzheimer
    - measures executive function
    - takes longer than MMSE
23
Q

7 A’s of Dementia

A
  1. Amnesia: loss of memory
  2. Aphasia: loss of language
  3. Agnosia: loss of recognition
  4. Apraxia: loss of purposeful movement
  5. Altered perception: loss of visual acuity
  6. Apathy: loss of initiation
  7. Anosognosia: no knowledge of disease
24
Q

Responsive Behaviours in Dementia

A

over 90% experience responsive behaviours, aka behavioural and psychological symptoms of dementia (BPSD)

verbal and physical aggression with psychosis

refusing care, refusing meds, refusing to bath

25
Q

Investigate the Behaviour (The ABCs)

A

Activator
(what happened just before B?)

Behaviour
(what is the behaviour, who is present, where and where?)

Consequence
(what happened just after B?)

26
Q

Managing BPSD

A

Apply person-centred care principles

  • relationship
  • environment
  • abilities
  • personhood

Prioritize non-pharmacological options

Pleasant events can be a distractor

27
Q

Sundowning in Dementia

A

Confusion/agitation gets worse as day progresses

hypothesis: decision fatigue over course of day and less resilience to control behaviours

28
Q

Nursing Interventions for Dementia

A
  • follow a set routine
  • don’t rush and provide extra time for communication or tasks
  • keep instructions simple
  • reduce distraction, offer snack
  • don’t argue or correct
  • be flexible
  • caution the use of prn meds for agitation, behavioural interventions work best
29
Q

Depression

A

Mood disorder characterized by a pervasive low mood or a loss of interest in activities and difficulty with:
sleep, appetite, energy, concentration, worthlessness, motor slowing, suicidal ideation

Lasting > 2 weeks

Most misdiagnosed, under-diagnosed and underrated illness

30
Q

Risk Factors for Depression

A

Physical

  • chronic disease
  • acute heart attack
  • organic brain disease
  • endocrine/metabolic disease
  • malignancy
  • chronic pain and disability

Psychosocial

  • social isolation
  • change in financial
  • being a carer
  • change in role and loss of social status
  • bereavement and loss
  • difficulty adapting to illness/pain/disability
  • history of depression
  • institutionalization
31
Q

Depression in older adults

A

Not a normal part of aging

Endorse physical complains but deny sadness

Worsens other illnesses

32
Q

Assessment for Depression

A

a. Geriatric Depression Scale

b. ED-Depression Screen
(Sad? Helpless? Blue?)

*exploring suicidal ideation is important if depression is likely!

33
Q

Interventions for Depression

A

Depression is treatable!

a. Medications
- antidepressants
- meds for associated agitation and psychosis

b. Supportive Care Strategies
c. Electroconvulsive Therapy (ECT) - most effective!

34
Q

Interaction/Supportive Care

A

Support the person by:

  • understanding that behaviour is due to an illness and recovery is more complicated than just “trying harder”
  • offering reassurance, don’t push beyond what the person is capable of doing at the time
  • listening
35
Q

Three D’s

A

Common Features:

  1. Confusion
  2. Irritability
  3. Disrupted sleep

Differentiating Features:

a. time course
b. causes
c. interventions

NUR360 (13 decks)

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