neurocognitive disorders Flashcards
Delirium - s/sx - and is it better or worse at night?
inability to focus attention, change in psychomotor activity, incoherent speech, disorientation, hallucinations, illusions, acute onset over hours or days, usually temporary, clinical features fluctuate during the day, often worse at night
delirium - causes
systemic infections - UTIs, fever, endocrine disorders, seizures, metabolic disorders (e.g. hypoglycemia, hypoxia), trauma (psych. or physical), sensory or sleep deprivation, substance intoxication or withdrawal (Etoh and other CNS depressants), medications (e.g., anticholinergics, inc. psych meds), electrolyte imbalance, CVA, brain abscess, post-operative states
delirium - nursing interventions
First priority is to identify the underlying cause (e.g. infection) and treat it! From a psych standpoint, keeping patient safe and close observation is best in most cases.
Normal Forgetting (process that comes with aging) - what age? and neurons?
recall processes begin slowing around age 40, names after 60-70
memory remains intact, but there is decreased speed of info retrieval
some decrease in attention span, abstraction and naming ability
decrease in neurons, decrease in their processing ability
increasing evidence that staying active, both cognitively and physically, helps slow this process (“use it or lose it!”)
Depression (sometimes referred to “pseudodementia” in the elderly) - what do pts complain of?
common in the elderly
general slowing of all mental processes; the pt will c/o forgetfulness, difficulty concentrating, and be very bothered by it
recall
Dementia (now referred to as Mild Neurocognitive Disorder or Major Neurocognitive Disorder in the DSM-5)
denies or underestimates mental impairment (insight diminishes as illness progresses) they usually know on some level.
recall, spatial orientation and recognition impairment; memory impairment (esp short-term) is a hallmark feature, esp in the early stages
hallucinations are rare, delusions poorly structured and paranoid (this would be delirium)
appetite intact
disoriented (wandering is a huge problem)
emotionally labile, agitation is common
often disinhibited (e.g. disrobing in the dayroom)
dementia - s/sx (aaac, it’s dementia)
s/sx vary in specifics & degrees depending on extent of illness
apraxia (problems with daily living), agnosia, aphasia, confabulation
apraxia
**inability to perform once familiar tasks (know this). trying to rush someone is a trigger.
agnosia (agonize over objects)
agnosia (can’t recognize objects)
confabulation - do they know they’re doing it?
when someone makes up stories to fill in memory gaps - to deal w/ low self-esteem. it’s not done on purpose - they don’t know they’re doing it. validate the emotion, don’t need to challenge them on it.
Major Causes of Neurocognitive Disorders - and more common in women or men?
There are about 100 causes, including alcohol and drugs of abuse, medications, traumatic brain injury (TBI), Parkinson’s disease, Huntington’s disease, frontotemporal lobe damage and Prion disease. Below are listed some of the most common types/causes. women more likely to develop dementia
causes of neurocognitive - meds (the one you’re afraid of)
benzos, alcohol, psychotropic, topamax, brain injury, carbs,
Neurocognitive Disorder due to Alzheimer’s Disease (AD)
Slow onset, progressive deterioration of mental and physical functions, entire spectrum of dementia features as listed above; sxs frequently become worse at night (sundowning) decreased brain volume on CT, decreased nutrient uptake on PET, decreased acetylcholine on autopsy (in contrast to normal aging), neurofibrillary tangles and senile plaques (abnormal protein), increased glutamate. betamalayoid plaques***none of the meds are working.
cause of alzheimers (ape)
genetic factors play a role, esp in early onset AD; ApoE4 is biggest known genetic risk factor***know for exam
alzheimer’s risk factors
head trauma, cardiovascular disease, social isolation, diabetes, metabolic syndrome, depression, hypothyroidism, alcohol and long term BZD use
Neurocognitive Disorder with Lewy Bodies (aka Diffuse Lewy Body Disease (DLBD) (lewy is a rapid psychotic) - is it fast or slow progression? and what type of hallucinations?
s/sx – similar to AD (alzheimers), but progresses more rapidly, often with earlier psychosis (esp. VH) and Parkinson-like sxs
DLBL - curable?
progressive and incurable
“Lewy bodies” are
eosinophilic inclusion bodies in the cerebral cortex and the brainstem
Vascular Neurocognitive Disorder (also called multi-infarct dementia) - how is the decline?
s/sx – probably a result of multiple “small strokes” (transient ischemic attacks); sudden onset is common; the pattern of decline is more irregular compared with AD
Vascular Neurocognitive Disorder (also called multi-infarct dementia)
generally considered the #2 cause of dementia (about 10-20% of all cases)
irreversible; often progressive; clients can sometimes regain functions via other neural pathways; ‘cascade’ of CVAs can exacerbate and make necessary life changes difficult
Neurocognitive Disorder Due to HIV Infection (aka HIV/AIDS dementia)
s/s – main differentiating features are that clients
are HIV positive, and often have been for years
are generally a lot younger than with other dementias
HAART meds help prevent it; treatment of opportunistic infections (that affect the brain) can even help treat/reverse the dementia sxs
Diagnosis of Neurocognitive Disorder
Mini Mental Status Exam (MMSE) – this is NOT the same as the full MSE, but rather focuses on neurocognitive function.
Also, ask about onset of sxs, PMH, PSA, etc.
be calm and pt w/ ppl w/ dementia, and validate.
General Nursing Care for Clients with Neurocognitive Disorder
Communication: stay calm and keep it simple; focus on one thing at a time. Encourage pt to reminisce about “the old days” (LTM is often somewhat intact, even when STM impairment is severe)
focus on what the patient can do
For moderate to severe dementia, DON’T insist on correcting the pt/reality orientation… this will only agitate them further.
Redirect pts who wander; use large signs with pictures to help pts with end-stage dementia.
General Nursing Care for Clients with Neurocognitive Disorder - what to do for apraxia
For apraxia/self care deficits, encourage independence, but assist as needed. Allow plenty of time for ADLs and try again later if pt becomes agitated.
Maintain consistency of staff/caregivers and a daily routine.
Don’t forget the family! Caregivers need support and respite. Remember to validate their despair over slowly losing a loved one to dementia. More info on grieving below…
KNOW BASIC MEDS FOR DEMENTIA - cholenestarase inhibitors and namaenta - decreases glutamate
stages of grief (DAB DA grief)
Denial (“No, it can’t be true!”)
Anger (at God, the universe, etc; may be displaced onto innocent people)
Bargaining (again, with God, the universe, etc.) – “If you let me live to see my son graduate college, I’ll . . . (go to church every Sunday, apologize to everyone, etc.)”
Depression
Acceptance
Normal/healthy grieving –
Usually lasts 6-8 weeks for the acute stage, but complete resolution of the grief response may take years.
Dysfunctional/maladaptive grieving
Failure to grieve can lead to dysfunctional grieving later. Common factors include:
Guilt over unresolved conflicts/negative feelings with dying/deceased SO
Heavy emotional dependence on the deceased
Young age of the deceased – parents are not supposed to outlive kids
Lack of social support
Death from a social stigma, e.g., AIDS, suicide, illegal substance use
Unexpected death, e.g., MVA (motor vehicle accident), murder, suicide
Hx of mental illness, including substance abuse
how is appetite w/ dementia?
appetite usually stays the same w/ dementia
depression - what remains intact?
spatial orientation, and recognition remain mostly intact
often triggered or exacerbated by stress or loss
loss of appetite, decrease in activity, flat affect are common
oriented
depression - better or worse as day goes on
no wandering; sxs often improve as the day progresses
retains social inhibitions
which pts sundown?
ask about diurnal pattern - ppl w/ dementia usually sundown. the opposite is usually true w/ depression.
does dementia cause paranoia?
no, this would be delirium
Lewy bodies - what makes it worse?
.know this. Symptoms are exacerbated by typical neuroleptics and anti-Parkinson meds. Parkinson’s dementia (PD) has Lewy bodies in different areas of brain. Eventually develops in 20-60% of PD clients.
lewy bodies - symptoms (lewy gets dizzy when he sleepwalks)
orthostatic hypotension and REM sleep disorders - sleep walkers seen in Parkinson’s and lewy body***
MMSE - points
- total of 30 points . 25 or greater is normal, 19 - 24 - mild, 10 - 18 - moderate, 9 or below is severe.
interventions for delusions/confusion resulting in agitation:
validate pt’s feelings and gently redirect/distract pt to something else.
delirium - what drugs to use (hal and atty have delirium)
If violent or self-injurious, commonly used drugs are haloperidol (Haldol) and lorazepam (Ativan), but polyphabrmacy can exacerbate delirium, so use only what is needed for safety.
REM sleep disorder
lewy body & parkinson’s
beta amyloids
alzheimers
esnophils
lewy body
