Dementia & Alzheimer's Dementia Flashcards
The number of people with this disorder is growing because more people now survive into the high-risk period for dementia, which is middle age and beyond.
Dementia statistics
Neurocognitive disorders are disorders in which a clinically significant deficit in cognition or memory exists, representing a significant change from a previous level of functioning.
Dementia
Living longer
Middle-aged and beyond
Memory is the 1st thing to see affected
Dementia
A mental state characterized by a disturbance in level of awareness and a change in cognition
- Dementia is not a normal process of aging.
- Develops rapidly over a short period.
Delirium
- difficulty sustaining and shifting attention
- extreme distractibility
- disorganized thinking
- speech that is rambling, irrelevant, pressured, and incoherent
- impaired reasoning ability and goal-directed behavior
- disorientation to time and place
symptoms of delirium
confusion excitement disorientation clouding of consciousness -time & place hypervigulance hyperawarness happening stupor/semi-coma
Symptoms of delirium
- Impairment of recent memory
- Misperceptions about the environment, including illusions and hallucinations
- Disturbance in level of consciousness, with interuption of the sleep-wake cycle
- psychomotor activity that fluctuates between agitation and restlessness and a vegetative state
- emotional instability
Symptoms of Delirium
- Tachycardia
- Sweating/diaphoresis
- Flushed face
- Dilated pupils
- Elevated blood pressure
- Usually begins abruptly; type of underline problem. polypharmacy, could be a UTI
- Can have a slower onset if underlying etiology i systemic illness or metabolic imbalance
- Duration is usually brief and subsides completely for underlying
Symptoms include autonomic manifestations
Infections, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, others;
-Never chronic; must be treated, underlying problem.
Delirium due to a general medical condition
Predisposing Factors
Maybe caused by intoxication o withdrawal from certain substances, such as
_Anticholingergics, antihypertensives, corticosteroids, anticonvulsants, analgesics and others
_Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, and others
_Toxins, including organic solvents and fuels, lead, mercury, arsenic, carbon monoxide, and others
(Smallest dose given so toxic levels aren’t reached)
Substance-Induced Delirium
Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking.
Neurocognitive Disorder
Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms. Mild NCD has also been called Mild Cognitive Impairment. Major NCD constitutes what was previously described in the DSM as dementia.
Neurocognitive disorder
those in which the disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (Alzheimer’s disease)
Primary NCD’s
caused by or related to another disease or condition (ie. HIV, or cerebral trauma) AIDS dementia; opportunistic disease happens
Secondary NCD’s
- Impairment exists in abstract thinking, judgement, and impulse control
- Conventional rules of social conduct are disregarded
- Personal appearance and hygiene are neglected
- Language may or may not be affected; asphasia
- Personality change is common
Neurocognitive Disorder
Symptoms
Reversible NCD may be more appropriately termed
-It can occur as a result of
Stroke
Depression
Side effects of medications
nutritional deficiencies; ie. alcoholics forget to eat.
metabolic disorders
temporary dementia
As the disease progresses, symptoms may include;
- aphasia
- apraxia
- irritability and moodiness, with sudden outbursts over trivial issues
- inability to care for personal needs independently
- wandering away from the home
- incontinence
Symptoms of Neurocognitive Disorder
unable to vocalize what they want
aphasia
inability to carry out motor activities
apraxia
AD; accounts for 50 to 60% of all cases of NCD
-Alzheimers’s Disease can be described in stages:
Stage 1, 2 and 3
Alzheimer’s Disease
No apparent symptoms. AD
Stage I AD
Forgetfulness; loss things, forget names; embarrassed of it. Maybe depressed from it. AD
Stage II AD
Mild cognitive decline AD
Stage III AD
Mild-to-moderate cognitive decline; Very noticeable; Confabulations. Ad
Stage 4; AD
Moderate cognitive decline; AD; unable to recognize family members. Immobility; ROM exercises need to be performed.
Stage 5; AD
Moderate-to-severe cognitive decline; sun-downing common. AD
Stage 6; AD
Severe cognitive decline
Stage 7; AD
Onset is slow and insidious;
Course of the disorder is generally progressive and deteriorating.
NCD due to Alzheimer’s Disease
Acetylcholine alterations; enzyme required
Plagues and tangles
Head trauma
Genetic Factors
Etiologies may include; AD
predisposing factors
NCD occurs as a result of significant cerebrovascular disease.
There is a more abrupt onset than is seen in association with AD, and the course is more variable.
-etiologies include;
hypertension; not being cared for adequately
cerebral emboli, cerebral thrombosis
Vascular NCD
Predisposing factors
-Occurs as a result of shrinking of the frontal and temporal anterior lobes of the brain.
-Previously called Pick’s disease
-Exact cause is unknown, but genetic appears to be a factor
lose ability with spoken & written language.
Frontotemporal NCD
predisposing factors
Amnesia is the most common neurobehavioral symptom following head trauma
Dementia due to traumatic brain injury
Repeated head trauma can result in Dementia Pugilistica with symptoms of
-emotional lability!
-dysarthria
-ataxia
-impulsivity
problems with speech due to lack of muscle control
Dementia Puglistica
dementia due to traumatic brain injury
Similar to Alzheimer’s disease, but progresses more rapidly.
Appearance of Lewy bodies in the cerebral cortex and brainstem
Progressive and irreversible
May account for 25% of all NCD cases
-manifested early
visual hallucinations; symptoms similar to EPS, Parkinsons
Dementia due to Lewy body disease
-Caused by a loss of nerve cells located in the substantia nigra and a decrease in dopamine activity.(in dopamine)
-Cerebral changes in NCD due to Parkinson’s disease sometimes resembles those of Alzheimer’s disease.
tremors @ rest
Dysphasia (monitor for)
Parkinson’s disease
Caused by brain infections with opportunistic organisms or by the HIV-1 virus directly. (secondary)
- Symptoms may range from barely perceptible changes to acute delirium to profound cognitive impairment.
- confusion psychosis
Dementia Due to HIV infection
Occurs as a result of reactions to, or the overuse or abuse of, substances such as
- alcohol
- inhalants
- sedatives, hypnotics, and anxiolytics
- medications that cause anticholinergic side effects
- toxins, such as lead and mercury
Substance-Induced Dementia
- This disease is transmitted as a Mendelian dominant gene
- Damage occurs in the areas of the basal ganglia and the cerebral cortex
- The client usually declines into a profound state of dementia and ataxia.
- Average course of the disease is based on age at onset, with juvenile-onset and late-onset having the shortest duration.
NCD due to Huntington’s disease
-The disorder is attributable to prion disease (ie. Creutzfeldt-Jakob disease or bovine spongiform encephalopathy)
-Onset of symptoms typically occurs between ages 40 to 60 year; course is extremely rapid, with progression from diagnosis to death in less than 2 years
-Five to 15% of cases have a genetic component
rapid
NCD due to Prion disease
Hypothroidism Hyperparathyroidism Pituitary insufficiency Uremia Encephalitis Brain tumor Pernicious anemia Thiamine deficiency Multiple sclerosis
NCD due to another medical disorder
Predisposing factors
Pellagra Uncontrolled epilepsy Cardiopulmonary insufficiency Fluid and electrolyte imbalances CNS and systemic infections Systemic lupus erythematosus
NCD due to another medical disorder
predisposing factors
Type, frequency, and severity of mood swings
- personality and behavioral changes
- Catastrophic emotional reactions
- cognitive changes
- language difficulties
- orientation to person, place, time and situation
- appropriateness of social behavior
- current and past use of medications, drugs, and alcohol
- possible exposure to toxins
- client and family history of specific illnesses
Nurses Knowledge
symptoms
The client hx: areas to be addressed:
Application of the Nursing process/assessment
Areas of concern to be addressed;
- orientation to place, person, time and situation
- appropriateness of social behavior
- current and past use of medications, drugs, and alcohol
- possible exposure to toxins
- client and family history of specific illness
the client hx
- assessment for diseases of various organ systems that -can induce confusion, loss of memory, and behavioral changes
- neurological examination to assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination
- psychological tests to differentiate between NCD and pseudodementia (depression)
Physical assessment
Include blood and urine to test for -various infections -hepatic and renal dysfunctions -diabetes or hypoglycemia -electrolyte imbalances -metabolic and endocrine disorders -nutritional deficiencies -presence of toxic substances Any sadness that lasts for 14 days clinically noted depression Depression most common mental illness and easily treatable.
Diagnostic laboratory evaluations
Assessment
Electroencephalogram EEG
Computed tomography CT scan
Positron emission tomography PET (metabolic activity of the brain)
Magnetic resonance imaging MRI (soft tissue damage)
Lumbar puncture to examine cerebrospinal fluid CSF (monitor any leakage in CSF)
Other diagnostic evaluations may include. NCD
Risk for trauma Disturbed thought processes Impaired memory Disturbed sensory perception Risk for other-directed violence Impaired verbal communication Self-care deficit Situational low self-esteem Grieving
Nursing Diagnosis/Outcome Identification
Has not experienced physical injury
Has not harmed self or others
Has maintained reality orientation to the best of his/her capability
Discusses positive aspects about self and life
Participates in activities of daily living with assistance
Outcome criteria for the client
Care plan for the client with a cognitive disorder is aimed at
- protection of self and others
- maintaining orientation to reality to the best of clients ability
- minimizing confusion
- fulfilling basic needs
- assisting and educating prospective caregivers about appropriate care for their loved ones
Safety, safety, safety
Planning and Implementation
Nature of Illness
Possible causes
What to expect
Symptoms
client/family education
Management of the illness
- ways to ensure client safety
- how to maintain reality orientation
- provide assistance with activities of daily living
- nutritional information
- difficult behaviors
- medication administration
- matters related to hygiene and toileting
Client/Family Education
Management of Illness
Support services
- financial assistance
- legal assistance
- caregiver support groups
- respite care
- home health care
Client/Family Education
support services
- Determination and correction of the underlying causes
- Staff remains with client at all times to monitor behavior and provide reorientation and assurance
- Room with low stimulus level
- Low-dose antipsychotic agents to relieve agitation and aggression (lowest possible dose)
- Benzodiazepines commonly used when etiology is substance withdrawal
Delirium
Based on the accomplishment of outcome criteria
Medical Treatment Modalities
[nursing process: evaluations]
Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes
Pharmaceutical agents for cognitive impairment
- Physostigmine (Antilirium)
- Tacrine (Cogex)
- Donepezil (Aricept)
- Rivastigmine (Exelon)
- Galantamine (Razadyne)
- Memantine (Namenda)
Dementia
Pharmceutical agents for Cognitive impairment
Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, and wandering.
-Risperidone (Resperdal)
-Olanzapine (Zyprexa)
-Quetiapine (Seroquel)
-Ziprasidone (Geodon) *EKG must be done 1st; cardiovascular problems
=These drugs cause fewer anticholinergic and EPS than older antipsychotics
=They carry a black box warning that all atypical antipsychotics are associated with an increased risk of death in elderly patients with dementia.
Medical Treatment Modalities
Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, and wandering
Haloperidol (Haldol)
-still commonly used because of its proven efficacy
-Higher potential for anticholinergic, EPS, and sedative effects than with the atypical antipsychotics
-Carries black-box warnings assoc. with increased risk of death in elderly patients with dementia (ND)
`Monitor wandering, thought disturbances, and hallucinations
Medical Treatment Modalitites
Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, and wandering
Often considered first-line due to favorable side effect profile
SSRI’s;
-Pharmaceutical agents for depression
Medical Treatment Modalitites
Often avoided due to anticholinergic and cardiac side effects
Tricyclic antidepressants
-Pharmaceutical agents for depression
Medical Treatment Modalitites
Good choice for clients with insomnia; given in PM
Trazodone (Desyrel)
-Pharmaceutical agents for depression
Medical Treatment Modalitites
Helpful in treatment of severe apathy; can induce psychosis; must monitor
Dopaminergic agents
-Pharmaceutical agents for depression
Medical Treatment Modalitites
- Chlordiazepoxide (Librium)
- Alprazolam (Xanax)
- Lorazepam (Ativan)
- Oxazepam (Serax)
- Diazepam (Valium)
Pharmaceutical agents for anxiety (should not be used routinely for prolonged periods)
Low dose because of sedating short life
- Flurazepam (Dalmane)
- Temazepam (Restoril)
- Triazolam (Halcion)
- Zolpidem (Ambiem)
- Zaleplon (Sonata)
- Ramelteon (Rozerem)
- Eszopiclone (Lunesta)
- Trazodone (Desyrel)
- Mirtazapine (Remeron)
Pharmaceutical agents for sleep disturbances (for short term therapy only)
Dosage adjustments with regards to physiological changes in aging clients must be made with all medications
-lowest dose possible that can give them highest affects.
Pharmaceutical agents for dementia and other NCD’s
Duration of the disorder is commonly brief. Reversible sudden change in Mental Status; medication
Delirium
Client with this disorder uses confabulations to hide cognitive deficits.
NCD; neurocognitive disorder
Symptoms of this disorder may be confused with depression.
NCD; neurocognitive disorder
Can be caused by a series of small strokes.
NCD; neurocognitive disorder
Is commonly reversible
Delirium
Can occur as the result of seizures.
Delirium
Level of awareness is affected.
Both; delirium and NCD
Reversibility occurs in only a small percentage of cases.
NCD
Severe migraine headache can lead to this condition.
Delirium
Personality change is common with this condition.
NCD
Illusions and hallucinations are common symptoms.
Delirium
Symptoms can occur as a result of cocaine intoxication.
Delirium
Symptoms can occur as a result of alcohol withdrawal.
delirium
Can occur as a result of head trauma.
Both; Delirium and NCD (neurocognitive disorder)
Disturbance in memory is commonly the first symptom.
NCD
is a mental state characterized by a disturbance of cognition, which is manifested by confusion, excitement, disorientation, and a clouding of consciousness. Hallucinations and illusions are common.
- disturbance in attention and awareness and a change in cognition that develop rapidly over a short period.
- extreme distractibility
- disorganized thinking
- incoherent speech, unpredictably switches subjects.
Delirium
A term that is used to describe cognitive functions closely linked to particular areas of the brain that have to do with thinking, reasoning memory, learning and speaking.
Neurocognitive
inability to communicate through speech, writing or signs, caused by dysfunction of brain centers
aphasia
creating imaginary events to fill in memory gaps.
confabulation
a phenomenon in NCD in which the symptoms seem to worsen in the later afternoon and evening.
sundowning
over abundance in AD brain
-tau protein; chemically altered. stabilizes the neuron
plaques and tangles
Acetylcholine alterations; enzyme required to produce acetylcholine dramatically reduced
possible hypotheses; possible causes of AD
onset slow and insidious; generally progressive and deteriorating
NCD/AD
cognitive symptoms due to significant cerebrovascular disease.
progressive intellectual deterioration occurs. 2nd most common form of NCD, after AD. More Abrupt onset and runs a highly variable course.
-problem with reflexes, gait & muscles. weakness 1st.
Small strokes killing many areas of the brain.
“silent strokes”
Vascular NCD
repeated offenders “boxers”; emotional lability, dysarthria, ataxia, and impulsivity.
dementia pugilistica
a loss of full control over muscle movements
ataxia
similar to AD, progress more rapidly. earlier appearance of hallucinations, and parkinsonian features.
-distintive by presence of Lewy bodies-eosinophilic inclision bodies; cerebral cortex brainstem.
Pt’s highly sensitive to EPS effects of antipsychotic meds; progressive and irreversible in 25% of cases.
NCD; Lewy Body Dementia
- deficiency of neurotrans; acetylchline is inactivated by the enzyme acetylcholinesterase
- (Acts as acetylcholinesterase inhibitors which slows the degradation of acetylcholine, thereby increasing concentrations of the neurotransmitters in the cerebral cortex.
- Lessens the disease process; no evidence it alters the course of the disease.
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Cholinesterase inhibitor physostigmine (Antilirium)
Mild to Moderate AD
Donepezil (Aricept)
slows the degradation of acetylcholine; thereby increasing concentrations of neurotransmitters in the cerebral cortex.
Mod to severe AD
program that provides palliative and supportive care to meet the special needs of people who are dying and their families
hospice
living will or durable power of attorney.
advance directives
