Dementia Delirium Depression Flashcards
Exam 2
Cognitive Status:
Cognition: What is it?
process by which information is learned, stored, retrieved, and used by the individual.
Cognitive Status:
Cognition: What kind of changes can occur with cognition?
Many age-related changes
Cognitive Status:
Memory: How is it long term?
Long-term remains relatively stable
Cognitive Status:
Memory: How is it short term?
Short-term exhibits more substantial changes
Cognitive Status:
What is the most important risk factor for developing dementia?
Age – most important risk factor for developing dementia
Cognitive Status:
What part of aging is dementia considered?
Dementia isn’t normal part of aging –it’s a Disease
Cognitive Status:
Senility: What kind of term is it?
Senility (old-fashioned term for dementia)
Cognitive Status:
Senility: Senility (old-fashioned term for dementia) using the two interchangeably implies what?
Senility (old-fashioned term for dementia) using the two interchangeably implies that characteristics of dementia are typical of advancing age — which is not true
Cognitive Status:
What does dementia involve?
Dementia itself involves significant cognitive decline that interferes with daily life and functioning.
Cognitive Status:
What kind of cognitive changes does aging do?
Normal aging may involve some cognitive changes, but these are generally mild and do not impede independence.
Cognitive Status
The normal cognitive changes associated with aging include what? How do they progress and effect daily living?
The normal cognitive changes associated with aging include mild memory and processing issues that generally do not progress over time nor interfere with daily functioning.
Cognitive Status
Mild cognitive impairment (MCI): What is it?
Mild cognitive impairment (MCI) is an intermediary diagnosis between normal cognition and dementia, in which a patient has demonstrable cognitive decline on examination, though not severe enough to affect independence in daily functioning.
Other Causes of Cognitive Changes
Parkinson’s disease
Chronic subdural hematoma
AIDS
Neurosyphillis
Liver Disease
Huntington’s disease
Brain Tumors
Hypothyroidism
Alcoholism
Medications
Vitamin deficiencies:
Other Causes of Cognitive Changes:
Medications like:
Narcotics,
hypnotics,
antiparkinsonian drugs,
antihistamines,
Other Causes of Cognitive Changes:
Vitamin deficiencies like:
VitaminB1,
Vitamin B12,
Folate
Cognitive Impairment:
What may it be associated with?
Cognitive impairment may be associated with psychosocial factors
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors
Serious losses
Difficult relationships
Changes in social roles
Loneliness
Poverty
Unplanned moves
Relocation stress
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Relocation stress ( can be due to loss of familiar environment, loss of control, change in routine, health concerns, fear of the unknown)
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: What is it often referred to as:
Relocation stress - often referred to as “transfer trauma” or “relocation syndrome,”
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: When it is experienced?
is a phenomenon observed in older adults, particularly those in institutional settings, when they experience a move or transfer from one living environment to another.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: When it is experienced?
It is a multifaceted response to the anxiety and stress of such a move, especially when the older individual may not have had a say or active role in the decision-making process.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Loss of Familiar Environment
A move can mean leaving behind a familiar and comforting environment which may have been their home for many years.
This can result in feelings of grief and loss.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Loss of Control:
Older adults might feel they have little or no say in the decision to move, leading to feelings of powerlessness or lack of control over their own lives.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Change in Routine:
Established routines can provide comfort and predictability. A move can disrupt these routines.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Health Concerns:
Many older adults relocate due to health issues.
The combined stress of health problems and relocation can be overwhelming.
Cognitive Impairment:
Cognitive impairment may be associated with psychosocial factors like
Relocation stress: Causes and factors include
Fear of the Unknown:
Moving to a new place can be intimidating because of uncertainties about the new environment, caretakers, or neighbors.
Dementia:
What kind of diagnosis is it?
An “umbrella” diagnosis
Dementia:
What kind of medical term is it?
Dementia: medical term of group of brain disorders characterized by gradual decline in cognitive abilities and changes in personality and behavior
Dementia:
Dementia is NOT what? What does this mean?
Dementia is not a single disease, but a group of diseases, each type is associated with a different cause and unique combination of symptoms
Dementia:
How to determine the type of dementia?
Not always able to determine type of dementia
Can have more than one type
Dementia:
What does the DSM-5, 2021 emphasize?
The DSM-5, 2021 emphasizes that a diagnosis requires a significant decline in cognitive function that interferes with independence in everyday activities.
Dementia:
What kind of assessment tool is used?
**Assessment Tool on classes: Use of the Functional Activities Questionnaire in Older Adults with Dementia.
Dementia:
What is it a decline in?
Dementia is a decline in mental functioning, affecting memory, cognition, language, and/or personality.
Dementia
Cognitive impairment refers to what?
Cognitive impairment refers to a decline in at least one of the following cognitive domains:
language, executive function, complex attention, perceptual-motor function, social cognition, learning, and memory.
Dementia
Cognitive impairment refers to a decline in at least one of the following cognitive domains:
language,
executive function,
complex attention,
perceptual-motor function,
social cognition,
learning, and
memory.
Dementia
Cognitive impairment refers to a decline in at least one of the following cognitive domains:
How must the disturbance be?
The disturbance must interfere with independence in everyday activities and not be better explained by another neurocognitive disorder.
Slide 6: Functional Activities Questionnaire Administration
Dementia: How is the disease usually?
A long-term, usually irreversible condition involving degeneration in brain function
Dementia:
The brain function affected depends on what?
The brain function affected depends on the type of dementia
Dementia
Pathophysiology for Dementias in general :
includes what?
Neuronal Death:
Neurotransmitter Changes:
Structural Brain Changes:
Inflammation:
Dementia
Pathophysiology for Dementias in general :
Neuronal death: Most forms of dementia involve what?
Neuronal Death: Most forms of dementia involve the death of nerve cells (neurons) in the brain.
Dementia
Pathophysiology for Dementias in general :
Neurotransmitter Changes: What occurs with this?
The levels or functioning of chemicals that nerve cells use to communicate (neurotransmitters) may be altered.
Dementia
Pathophysiology for Dementias in general :
Structural Brain Changes: What occurs with this?
Over time, specific areas of the brain may shrink (atrophy) in some types of dementia.
Dementia
Pathophysiology for Dementias in general :
Inflammation: What occurs with this?
Some dementias, including AD, involve inflammatory processes in the brain.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
includes:
Amyloid Plaques:
Neurofibrillary Tangles:
Neurotransmitter Disruption:
Brain Atrophy:
Inflammation:
Oxidative Stress:
Vascular Factors:
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Amyloid Plaques: What is the hall mark of AD? What do plaques do?
A hallmark of AD is the accumulation of beta-amyloid peptides, which clump together to form plaques in spaces between neurons.
These plaques are believed to block cell-to-cell signaling and trigger an immune response that can lead to inflammation and further damage.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Neurofibrillary Tangles: Inside neurons, what is a characteristic feature?
Inside the neurons, another characteristic feature of AD is the presence of neurofibrillary tangles.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Neurofibrillary Tangles: What are tangles made from?
These tangles are made of a protein called tau.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Neurofibrillary Tangles: In AD, what happens to Tau?
In AD, tau undergoes chemical changes that cause it to form twisted tangles, leading to transport problems inside the neurons and eventual neuron death.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Neurotransmitter Disruption: As AD progresses, what happens?
As AD progresses, there’s a decrease in the level of the neurotransmitter acetylcholine, which plays a vital role in memory and attention.
The neurons that produce acetylcholine are damaged and lost in AD.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Brain Atrophy: What happens with the damage in AD? What is the first region to be affected?
Over time, the damage in AD spreads, and there’s a marked shrinkage (atrophy) of brain tissue.
The hippocampus, crucial for memory formation, is usually the first region to be affected.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Inflammation: What becomes activated in AD? What do they release?
Glial cells, which support neuron function, become activated in AD and release inflammatory molecules that contribute to damage.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Oxidative Stress:
There’s evidence that oxidative stress plays a role in AD.
Reactive oxygen species (free radicals) can damage neurons and are found in higher levels in the brains of people with AD.
Dementia
Pathophysiology of Alzheimer’s Disease (AD):
Vascular factors: What may contribute to AD progression
Reduced blood flow, microbleeds, and other vascular changes may contribute to AD progression.
Dementia:
What are the types of dementia?
- Alzheimer’s Disease (AD)
- Vascular Dementia
- Lewy Body Dementia
- Frontotemporal Dementia
- Parkinson’s Disease Dementia
Dementia:
Alzheimer’s Disease (AD): Presentation
Patients often present with memory loss as an early symptom.
As AD progresses, other areas of the brain are affected leading to challenges in reasoning, visual spatial abilities, and eventually, speech and movement.
Dementia:
Alzheimer’s Disease (AD): Areas of the brain affected
Alzheimer’s primarily impacts the hippocampus, especially in the early stages.
The hippocampus is involved in memory formation.
Dementia:
Vascular Dementia: Areas of the Brain Affected
Why does this form of dementia arise?
This form of dementia arises due to reduced blood flow to various parts of the brain.
Dementia:
Vascular Dementia: Areas of the Brain Affected
The specific regions affected depend on the blood vessels that are blocked or damaged.
Dementia:
Vascular Dementia: Presentation
How do symptoms appear? What are they? How is progression?
Symptoms can be sudden if they are due to a stroke.
They might include confusion, difficulty speaking, or weakness on one side of the body.
The progression can be step-wise, with periods of stability followed by sudden declines.
Dementia:
Lewy Body Dementia (LBD): Areas of the Brain Affected
LBD is associated with abnormal protein deposits (Lewy bodies) that form in various parts of the brain, including the cortex and brainstem.
Dementia:
Lewy Body Dementia (LBD):
Presentation:
Beyond memory and cognitive challenges, LBD often involves visual hallucinations, Parkinsonian movement symptoms (like rigidity or shuffling walk), and fluctuations in alertness.
Dementia:
Frontotemporal Dementia (FTD):
Areas of the Brain Affected:
As the name suggests, FTD affects the frontal and temporal lobes of the brain.
Dementia:
Frontotemporal Dementia (FTD):
Areas of the Brain Affected: As the name suggests, FTD affects the frontal and temporal lobes of the brain.
These regions are associated with what?
These regions are associated with personality, behavior, and language.
Dementia:
Frontotemporal Dementia (FTD):
Presentation: How does it begin? How may patients act?
Presentation: Unlike other dementias that start with memory problems, FTD often begins with behavioral changes or language disturbances.
Patients might act inappropriately or impulsively, show apathy, or exhibit speech difficulties.
Dementia
Parkinson’s Disease Dementia (PDD)
Areas of the Brain Affected:
This type of dementia arises in the context of Parkinson’s disease, which primarily affects the basal ganglia and substantia nigra, regions associated with movement.
However, over time, other brain regions become involved.
Dementia
Parkinson’s Disease Dementia (PDD)
Presentation: When does it present? What symptoms?
This dementia typically occurs after a person has had Parkinson’s disease for some time.
Beyond the motor symptoms (like tremors, rigidity), individuals might show slowed thinking, difficulty concentrating, and visual hallucinations.
Dementia: 4 most common typesTable 15-2 :Distinguishing Features of Common Types of Dementia
What is the most common type of dementia? Who has a higher chance of developing this?
Alzheimer’s
Women have a higher chance of developing
Dementia: 4 most common typesTable 15-2 :Distinguishing Features of Common Types of Dementia
What is the second most common dementia? Who is at higher risk?
Lewy body dementia
Men at higher risk
Dementia: 4 most common typesTable 15-2 :Distinguishing Features of Common Types of Dementia
What is the Nursing Goal for dementia:
Identifying factors affecting the client’s functioning and quality of life.
Dementia: 4 most common typesTable 15-2 :Distinguishing Features of Common Types of Dementia
What is the most common dementia for people less than 60? What is it associated with?
Frontotemporal Dementia
( here gene mutation associated with it)
Dementia: 4 most common typesTable 15-2 :Distinguishing Features of Common Types of Dementia
–Mixed dementia
- more than 50% of those whose brains met pathological criteria for Alzheimer had pathological evidence of one or more coexisting dimensions (NIA project)
Comments of slide 8
Which of the following is the best description of dementia?
A. Manifestation of a treatable condition
B. Syndrome of impaired cognition
C. Single disease
D. Complication of illness
B. Syndrome of impaired cognition
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
memory impairment,
aphasia,
apraxia,
agnosia,
amnesia,
anomia and
impaired executive functions*
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Amnesia: What does it refer to?
Memory loss
Dementia:
What is the most most easily visible and common sign of Alzheimer’s dementia?
Amnesia
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Amnesia: How does it typically begin? How does it progress?
Memory loss in Alzheimer’s disease typically begins withshort-term memoryand progresses to a decline inlong-term memory.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as: Aphasia
Aphasia (Inability to express oneself through speech)
Aphasia is a term used to describe impaired communication
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: How may is be classified?
Aphasia may be classified asexpressive aphasia, where someone is unable to find the right words or may say them incorrectly, or
receptive aphasia, where the ability to understand, receive and interpret language is impaired.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: What kind of aphasia is present in Alzheimer’s?
Alzheimer’s disease affects both expressive and receptive aphasia.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: In the early stages of Alzheimer’s what may occur? How does it progress?
In the early stages of Alzheimer’s, there might be some mild difficulty withfinding the right word.
As Alzheimer’s progresses into the later stages, speech may become nonsensical and impossible to understand, and it may be difficult to determine how much of what you say is being comprehended.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: What an important form of communication?
**non-verbal communication—which is an important aspect of interacting with each other when cognition is intact—becomes that much more important when interacting with someone who is living with dementia.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: What can it include? What is important?
This can include basic tactics such as remembering to smile to reassure the client that you are there to help them, as well as more advanced non-verbal approaches such as demonstrating a task you want to have them complete, instead of just verbally saying it.
Maintain good eye contact and use a relaxed and smiling approach is important.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Aphasia: What else can it include?
Aphasia is commonly thought of as the impairment of speech and language, but it also can include the ability to read and write.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as: Anomia
Anomia (problems finding the name of things)
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as: Apraxia
Apraxia (misuse of objects, because of failure to identify them)
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as: Agnosia
Agnosia (inability to recognize familiar objects, tastes ,sounds and other sensations)
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Agnosia: What kind of impairment is it?
Agnosia is the impairment of the ability to receive or correctly understand information from the senses of hearing, smell, taste, touch, and vision.
Dementia:
It is a syndrome of impaired cognition caused by brain dysfunction and characterized by multiple cognitive deficits, such as:
Agnosia: What is an example?
For example :people with Alzheimer’s disease are often less able toidentify smellsor understand the feeling of a full bladder.
They also might not be able torecognize loved ones as the disease progresses.
Difficulty recognizing or interpreting visual shapes is frequently present in Alzheimer’s disease.
Agnosia may also be auditory, where the sense of hearing is intact but the ability to interpret what the sound means is impaired.
Dementia:
The presence of what is often part of a cognitive assessment?
Agnosia
Dementia:
What is one of the most common cognitive issues seen in dementia? What is it often associated with?
Apraxia
Apraxia is often associated with agnosia (loss of recognition) and/or aphasia (loss of language).
Dementia:
What is one of the most common cognitive issues seen in dementia? What is it often associated with?
Apraxia: What is the person unable to do?
The person is unable to perform tasks or learned (familiar) purposeful movements on command even though they may understand the request or command.
Dementia
Criteria: Decline in memory (Amnesia) PLUS decline in one or more of the following:
Ability to generate coherent speech or understand written or spoken language (Aphasia)
And with finding the right words ( Anomia)
Ability to recognize or identify objects (Agnosia)
Ability to execute motor activities (Apraxia)
Ability to think abstractly, make sound judgments and plan and carry out complex tasks
Clinical Manifestations of Dementia
Early (Mild): includes
Forgetfulness
Short term memory impairment
Loss of initiative and interest
Decreased judgment
Geographic disorientation
Difficulty recognizing numbers
Clinical Manifestations of Dementia
Middle (Moderate): includes
Impaired ability to recognize fam and friends
Agitation
Wandering, getting lost
Impaired comprehension
Delusions
Behavioral problems
Clinical Manifestations of Dementia
Late (severe) : includes
Little memory, unable to process new info
Can’t understand words
Difficulty eating/swallowing
Unable to perform ADLs
Immobility
Incontinence
Clinical Manifestations of Dementia
What does research show about people with dementia and awareness?
Research shows that people with dementia are acutely aware of the fact that they are experiencing a cognitive deficit.
Clinical Manifestations of Dementia
Research shows that people with dementia are acutely aware of the fact that they are experiencing a cognitive deficit.
What is awareness associated with?
Awareness associated with higher levels of anxiety and depression.
Alzheimer Disease
What are factors that increase the risk for AD?
Advanced age
Family history of people who have a first-degree relative with AD (i.e., parent or sibling)
Diabetes
Traumatic brain injury
Depression
Chronic diseases
Genetic factors
Alzheimer Disease
Factors that increase the risk for AD:
Genetic factors?
Inheriting the APOE-E4 gene from one or both parents
Alzheimer Disease
Factors that increase the risk for AD:
Chronic diseases like?
Risks for cardiovascular disease: smoking, obesity, diabetes, hypertension, hypercholesterolemia
Alzheimer Disease
Factors that increase the risk for AD:
What does a simple blood test help with?
Simple blood test found to be up to 96% accurate in identifying elevated levels of beta amyloid and up to 97% accurate in identifying tau, even before symptoms begin to show, a new study suggests.
Alzheimer Disease
Factors That Decrease the Risk for AD:
What does a simple blood test help with?
Physical activity
- Diet that is low in saturated fats and rich in vegetables and vegetable-based oils
- Higher levels of education, which help build a “cognitive reserve”
- Engaging in social and cognitive activities
Alzheimer Disease
What interacts to contribute to AD onset?
genetic, environmental, and lifestyle factors likely interact in complex ways to contribute to AD onset and progression.
The effects of resistance exercise on cognitive function, amyloidogenesis, and neuroinflammation in Alzheimer’s disease
Slide 14 is time?
Gradual progression of brain atrophy is correlated with what?
Gradual progression of brain atrophy is correlated with stages of Alzheimer’s
Gradual progression of brain atrophy is correlated with stages of Alzheimer’s
What are the stages of Alzheimer’s?
- Mild Cognitive impairment
- Mild Alzheimer’s
- Moderate Alzheimer’s
- Severe impairment
Gradual progression of brain atrophy is correlated with stages of Alzheimer’s
What types of neurons are especially susceptible to Alzheimer’s?
Neurons that use the neurotransmitter acetylcholine are especially susceptible to the disease.
Gradual progression of brain atrophy is correlated with stages of Alzheimer’s
Cortical areas that are preferentially affected include the:
Cortical areas that are preferentially affected include the
hippocampus,
the amygdala,
the temporal cortex,
the olfactory system, and
intercortical connections.
Treatment of AD:
Broadly, what is the goal of treatment?
Disease slowing and management of functional Consequences :
Treatment of AD:
Disease slowing and management of functional Consequences :
Health promotion interventions:
Reassurance for anxiety and confusion
Redirection for unsafe or inappropriate behaviors
Management of BPSD
Medications
Treatment of AD:
Disease slowing and management of functional Consequences :
Health promotion interventions include:
Exercise nutrition,
Cognitive engagement
Treatment of AD:
Disease slowing and management of functional Consequences :
Medications: What do they do?
There is not currently a cure available for Alzheimer disease, but some drugs have been shown to slow the progression of the disease or help with symptoms/behaviors.
Treatment of AD:
Disease slowing and management of functional Consequences :
BPSD: What is it?
BPSD (behavioral and psychological symptoms of dementia)
Treatment of AD:
Disease slowing and management of functional Consequences :
What does treatment consist of?
How are treatment options?
Treatment for dementia consists of both pharmacological and nonpharmacological measures.
All treatment options are symptomatic in nature.
There are currently no disease-modifying agents to slow down or reverse the progression of neurodegenerative diseases.
Specific medications for Dementia include?
Cholinesterase Inhibitors:
NMDA (N-methyl-D-aspartate) receptor antagonists.
Combination medication
Cholinesterase Inhibitors:
Increase the concentration of acetylcholine and the duration of its action in synapses by inhibiting the degradation of acetylcholine
Cholinesterase Inhibitors include:
Donepezil (aricept)
Rivastigmine (exelon)
Galantamine (razadyne)
Cholinesterase Inhibitors include:
Donepezil (aricept)
Tx during all stages of disease
Cholinesterase Inhibitors include:
Rivastigmine (exelon)
Tx during all stages of disease
Cholinesterase Inhibitors include:
Rivastigmine (exelon): How does it differ from other drugs?
Exelon is less likely to interact with other drugs and may be safer and better tolerated in people.
Cholinesterase Inhibitors include:
Galantamine (razadyne):
Tx for mild-moderate AD
Galantamine is effective with cognitive and behavioral symptoms.
Cholinesterase Inhibitors:
What should not be done when taking these drugs?
No “drug holiday”
The effectiveness of cholinesterase inhibitors is diminished significantly if it is stopped and then restarted.
NMDA (N-methyl-D-aspartate) receptor antagonists.
Include:
Memantine ( Namenda) Tx for moderate-advance AD
NMDA (N-methyl-D-aspartate) receptor antagonists.
Memantine ( Namenda)
Tx for moderate-advance AD
Blocks excess of glutamate
What is a combination treatment for AD?
Namzaric is a combination of Memantine and Donepezil also approved totreat moderate-to-advance AD.
Slide 19
Assessment Tools include:
MOCA (Montreal Cognitive Assessment)
Mini Mental Status Exam (MMSE)
Mini-Cog
Assessment Tools include:
Mini Mental Status Exam (MMSE) purpose:
The MMSE is a widely used screening tool to assess general cognitive function, including orientation, registration, attention, calculation, recall, and language.
Assessment Tools include:
Mini Mental Status Exam (MMSE): How is it scored?
The maximum score is 30, with a score of 24 or above typically considered normal.
It uses a simpler scoring system with equal weight assigned to each question.
Assessment Tools include:
Montreal Cognitive Assessment (MoCA):
Purpose:
The MoCA is designed to detect mild cognitive impairment (MCI) and screen for various cognitive domains, including attention, memory, language, visuospatial abilities, executive functions, and orientation.
Assessment Tools include:
Montreal Cognitive Assessment (MoCA):
Scoring:
The maximum score is 30, with a score of 26 or above generally considered normal.
It uses a weighted scoring system to provide a more comprehensive assessment.
Assessment Tools include:
Montreal Cognitive Assessment (MoCA):
How does this test compare to the MMSE?
The MoCA is considered more sensitive in detecting MCI compared to the MMSE.
Length: The MoCA is longer and more extensive than the MMSE.
Assessment Tools include:
Mini-Cog
Purpose:
The Mini-Cog is a brief screening tool for cognitive impairment that combines a three-item recall test with a clock-drawing task.
Assessment Tools include:
Mini-Cog
Scoring:
It is scored based on the accuracy of recalling the three items and the quality of the clock drawing.
Assessment Tools include:
Mini-Cog
How does this test compare to the MoCA and MMSE?
Length: The Mini-Cog is shorter and quicker to administer compared to the MoCA and MMSE.
Behavioral and Psychological Symptoms of Dementia
include:
Aggression and agitation
Psychiatric symptoms (delusions)
Personality changes
Mood disturbances
Aberrant motor movements
Changes in sleep, eating, and appetite
Hypersexual behavior
Sundowning
Wandering
Behavioral and Psychological Symptoms of Dementia
Agitation: What can be done about this?
(Adequate lighting at night can reduce agitation that can happen when surroundings are dark.
Regular daylight exposure address day and night reversal problems)
Behavioral and Psychological Symptoms of Dementia
Sundowning:
(Fatigue, overstimulation,
fear of darkness, altered circadian rhythm)
Behavioral and Psychological Symptoms of Dementia
What do dementia related behaviors reflect?
Dementia-related behaviors reflect an attempt to communicate needs that the person may not consciously recognize and cannot verbally express.
Behavioral and Psychological Symptoms of Dementia
Addressing the needs of the person with dementia is best accomplished by:
Addressing the needs of the person with dementia is best accomplished by identifying the underlying causes of behavior.
Common BPSD (behavioral and psychological symptoms of dementia):
Agitation:
Apathy:
Depression:
Anxiety:
Hallucinations:
Delusions:
Sleep Disturbances:
Wandering:
Sundowning:
Repetitive Behaviors:
Sexually Inappropriate Behaviors:
Physical Aggression:
Vocal Outbursts:
Hoarding:
Paranoia:
Catastrophic Reactions:
Behavioral and Psychological Symptoms of Dementia - Nursing Care
Major nursing responsibility: What is it?
Look for contributing causes and implement strategies to prevent issues or minimize effects .
Behavioral and Psychological Symptoms of Dementia - Nursing Care
Person-centered approach: What should be set up?
Setting up a daily routine wake/sleep/meals/snacks/rest etc.
Behavioral and Psychological Symptoms of Dementia - Nursing Care
Person-centered approach: What should be implemented?
Implement regular rest periods (within the daily routine)
Behavioral and Psychological Symptoms of Dementia - Nursing Care
Person-centered approach: How should the environment be?
Maintain a clutter-free environment.
Place pictures of familiar people in very visible places.
Lay out clothing in the order in which the items are to be donned.
pictures, signs, and color codes for identifying places
Read slide 23
Treatment of the Behavioral Manifestations of AD with medications
What are behavioral illnesses?
Depression
Insomnia
Severe agitation, aggression and associate psychosis-delusions.
Anxiety/panic disorders
Treatment of the Behavioral Manifestations of AD with medications
Depression: What group of meds are used?
Selective serotonin reuptake inhibitor (SSRI) :
Tricyclic antidepressants
Treatment of the Behavioral Manifestations of AD with medications
Depression:
Selective serotonin reuptake inhibitor (SSRI): What is included in this?
-citalopram (Celexa)
-escitalopram (Lexapro)
-sertraline (Zoloft)
Treatment of the Behavioral Manifestations of AD with medications
Depression:
Tricyclic antidepressants: What kind of TCAs should be chosen?
Choose TCAs with a more favorable side effect profile, such as
Treatment of the Behavioral Manifestations of AD with medications
Depression:
Tricyclic antidepressants: What are examples?
nortriptyline (Pamelor)
or desipramine (Norpramin)
Treatment of the Behavioral Manifestations of AD with medications
Depression:
Tricyclic antidepressants: What kind of effects do nortriptyline (Pamelor) or desipramine (Norpramin) have compared to other TCAs?
Tend to have fewer anticholinergic and cardiovascular effects compared to other TCAs.
Treatment of the Behavioral Manifestations of AD with medications
Depression:
When taking SSRIs or TCAs, what does nursing education include?
Nursing- pt. teaching maintain fluids
Treatment of the Behavioral Manifestations of AD with medications
Insomnia: What is a med?
Melatonin with a darkened room
Treatment of the Behavioral Manifestations of AD with medications
Sever Agitation, aggression and associate psychosis-delusions: What is a med group?
Antipsychotics
Treatment of the Behavioral Manifestations of AD with medications
Sever Agitation, aggression and associate psychosis-delusions:
Antipsychotics like:
haloperidol (Haldol),
quetiapine (Seroquel)
risperidone (Risperdal)
olanzapine (Zyprexa)
aripiprazole (Abilify)
Treatment of the Behavioral Manifestations of AD with medications
Sever Agitation, aggression and associate psychosis-delusions:
Antipsychotics: How do they differ? Which drug is most effective?
Each one has slightly different effects on the brain and has its own potential risks and side effects.
The drug with the most evidence to support its use in dementia isrisperidone.
Treatment of the Behavioral Manifestations of AD with medications
Sever Agitation, aggression and associate psychosis-delusions:
Antipsychotics: Quetiapine?
Quetiapine (Seroquel)
has shown promise in thetreatment of psychosisin elderly patients with Alzheimer’s disease and Parkinson’s disease.
It improves psychosis in patients with Parkinson’s disease without exacerbating movement disorders
Treatment of the Behavioral Manifestations of AD with medications
Anxiety/panic disorders: med groups used?
Benzodiazepines
Non-Benzodiazepine Anxiolytic
Treatment of the Behavioral Manifestations of AD with medications
Anxiety/panic disorders:
Benzodiazepines: How is it used? Why?
(for short-term use due to addictive potential):
Treatment of the Behavioral Manifestations of AD with medications
Anxiety/panic disorders:
Benzodiazepines: Include what drugs?
lorazepam (Ativan) Benzo *addictive
diazepam (Valium) Benzo *addictive
Treatment of the Behavioral Manifestations of AD with medications
Anxiety/panic disorders:
Non-Benzodiazepines Anxiolytic: How is it used?
(a safer long-term option)
Treatment of the Behavioral Manifestations of AD with medications
Anxiety/panic disorders:
Non-Benzodiazepines Anxiolytic: What meds are included?
buspirone (BuSpar) *not a sedative not addictive
Treatment of the Behavioral Manifestations of AD with medications
How do benzos compare to non-benzos do?
While Benzos calms the body by binding with GABA receptors, buspirone (anxiolytics) acts on serotonin receptors.
Unlike Benzos buspirone is not addictive and causes less sedation than benzos.
Slide 26
Delirium:
According to the DSM-V Criteria, what is delirium?
DSM-V Criteria—it’s a syndrome
Delirium:
What is it?
Disturbance of consciousness with reduced ability to focus, sustain or shift attention—change in mental status and cognition or development of a perceptual disturbance not better accounted for by pre-existing dementia
Delirium:
How does disturbance develop?
Disturbance develops over a short period ( hours/days) fluctuate during the course of the day
Delirium:
What is the disturbance caused by?
Evidence from history, physical or labs that the disturbance is caused by the direct physiological consequences of a general medical condition
Occurrence of Delirium in Older Persons
Where does it mostly occur?
80%+ intensive care settings
Assessment Tool: Confusion Assessment Method (CAM):
What is it? Who can do this assessment?
Nursing assessment of delirium
The Confusion Assessment Method (CAM) is a standardized evidence-based tool that enables non-psychiatrically trained clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings.
Assessment Tool: Confusion Assessment Method (CAM):
What is vital?
Frequent assessment vital
Assessment Tool: Confusion Assessment Method (CAM):
What are the features?
Feature 1: Acute onset and fluctuating course
Feature 2: Inattention
Feature 3: Disorganized thinking
Feature 4: Altered level of consciousness
Assessment Tool: Confusion Assessment Method (CAM):
Feature 1: Acute onset and fluctuating course
Who is this feature usually obtain from? What indicates this feature is present?
This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions:
Is there evidence of an acute change in mental status from the patient’s baseline?
Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
Assessment Tool: Confusion Assessment Method (CAM):
Feature 2: Inattention
How is this feature positive?
This feature is shown by a positive response to the following question:
Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Assessment Tool: Confusion Assessment Method (CAM):
Feature 3: Disorganized thinking -
How is this feature positive?
This feature is shown by a positive response to the following question: Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Assessment Tool: Confusion Assessment Method (CAM):
Feature 4: Altered Level of consciousness -
How is this feature positive?
This feature is shown by any answer other than “alert” to the following question: Overall, how would you rate this patient’s level of consciousness?
Assessment Tool: Confusion Assessment Method (CAM):
Using the CAM tool, what would suggest a diagnosis of delirium?
Four-point algorithm; the presence of features 1 and 2 and either 3 or 4 are present (CAM +/positive), a diagnosis of delirium is suggested.
Assessment Tool: Confusion Assessment Method (CAM)
What can improve outcomes in elderly with delirium?
Early recognition and treatment can improve outcomes.
Assessment Tool: Confusion Assessment Method (CAM)
What is a key issue in recognizing delirium? What does this mean?
A key issue in recognizing delirium is understanding the older adult’s baseline and quickly identifying changes, which in the case of delirium can occur within hours.
Therefore, older adults should be assessed frequently
Assessment Tool: Confusion Assessment Method (CAM)
What are other versions of this?
There is also a CAM-ICU version for use with non-verbal mechanically ventilated patients
The CAM-S is a companion tool to the CAM that can be used to assess the severity of delirium
Assessment Tool: Confusion Assessment Method (CAM)
CAM-ICU: What does it take into account?
The CAM-ICU takes into account the unique challenges and characteristics of critically ill patients, such as the use of sedatives and mechanical ventilation.
Prodromal symptoms of delirium
include:
Restlessness
Anxiety
Irritability
Sleep disturbance
Prodromal symptoms of delirium may progress to delirium over how many days?
May Progress to full-blown delirium over 1 to 3 days ( Hours to days)
Risk Factors for Delirium
History of dementia, depression or previous delirium
Sensory impairment
Multiple chronic conditions
Increasing severity of illness
Polypharmacy
Increasing age
Immobility and
functional dependency
Sleep deprivation
Causes of delirium include:
Central Nervous System
Metabolic
Cardiopulmonary
Systemic illness
Causes of delirium include:
Central Nervous System like:
Head trauma
Causes of delirium include:
Metabolic like:
Acid base imbalance
Causes of delirium include:
Cardiopulmonary like:
MI
CHF
Causes of delirium include:
Systemic illness like:
Substance withdrawal
Infection
Sensory deprivation
Temperature dysregulation
Postoperative state
Drugs that cause delirium include:
Anesthetics
Analgesics
Antihistamines
Antihypertensives
Muscle relaxants
Psychotropic medications
Cardiovascular medications
Corticosteroids
Drugs that cause delirium:
When there is a change in cognition in a patient, what is the priority?
Nursing: Change in cognition in a patient –Priority is to assess their medications (after ABC and safety of course!)
Delirium:
3 Variants- what are they?
Hypoactive delirium
Hyperactive delirium
Mixed delirium
Delirium:
3 Variants-hypoactive delirium
This may include inactivity or reduced motor activity, sluggishness, abnormal drowsiness.
Delirium:
3 Variants-hyperactive delirium
This may include restlessness, agitation, rapid mood changes or hallucinations
Delirium:
3 Variants-Mixed delirium
Both hyperactive and hypoactive symptoms.
The person may quickly switch back from hypoactive and hyperactive states.
Nursing Care Strategies to Manage a Patient with Delirium
Nursing Priority: What is it?
Nursing Priority: low-dose oxygenation and maintain their fluid and electrolyte balance.
Nursing Care Strategies to Manage a Patient with Delirium
What should be done with meds?
Eliminate as many medications as you possibly can, since many medications are causative factors in delirium
Nursing Care Strategies to Manage a Patient with Delirium
What are a few things that should be done?
Consistent caregivers-evidence
Sensory deficits
Environment:
Physical activity:
Fluid and electrolyte balance
Strategies to Manage a Patient with Delirium
What are somethings that should be done?
Bowel and bladder
Safety
Psychological support
Sleep promotion
