neurocognitive disorders

Question 1

Delirium - s/sx - and is it better or worse at night?

Answer 1

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

Question 2

delirium - causes

Answer 2

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

Question 3

delirium - nursing interventions

Answer 3

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.

Question 4

Normal Forgetting (process that comes with aging) - what age? and neurons?

Answer 4

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!”)

Question 5

Depression (sometimes referred to “pseudodementia” in the elderly) - what do pts complain of?

Answer 5

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

Question 6

Dementia (now referred to as Mild Neurocognitive Disorder or Major Neurocognitive Disorder in the DSM-5)

Answer 6

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)

Question 7

dementia - s/sx (aaac, it’s dementia)

Answer 7

s/sx vary in specifics & degrees depending on extent of illness
apraxia (problems with daily living), agnosia, aphasia, confabulation

Question 8

apraxia

Answer 8

**inability to perform once familiar tasks (know this). trying to rush someone is a trigger.

Question 9

agnosia (agonize over objects)

Answer 9

agnosia (can’t recognize objects)

Question 10

confabulation - do they know they’re doing it?

Answer 10

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.

Question 11

Major Causes of Neurocognitive Disorders - and more common in women or men?

Answer 11

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

Question 12

causes of neurocognitive - meds (the one you’re afraid of)

Answer 12

benzos, alcohol, psychotropic, topamax, brain injury, carbs,

Question 13

Neurocognitive Disorder due to Alzheimer’s Disease (AD)

Answer 13

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.

Question 14

cause of alzheimers (ape)

Answer 14

genetic factors play a role, esp in early onset AD; ApoE4 is biggest known genetic risk factor***know for exam

Question 15

alzheimer’s risk factors

Answer 15

head trauma, cardiovascular disease, social isolation, diabetes, metabolic syndrome, depression, hypothyroidism, alcohol and long term BZD use

Question 16

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?

Answer 16

s/sx – similar to AD (alzheimers), but progresses more rapidly, often with earlier psychosis (esp. VH) and Parkinson-like sxs

Question 17

DLBL - curable?

Answer 17

progressive and incurable

Question 18

“Lewy bodies” are

Answer 18

eosinophilic inclusion bodies in the cerebral cortex and the brainstem

Question 19

Vascular Neurocognitive Disorder (also called multi-infarct dementia) - how is the decline?

Answer 19

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

Question 20

Vascular Neurocognitive Disorder (also called multi-infarct dementia)

Answer 20

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

Question 21

Neurocognitive Disorder Due to HIV Infection (aka HIV/AIDS dementia)

Answer 21

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

Question 22

Diagnosis of Neurocognitive Disorder

Answer 22

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.

Question 23

General Nursing Care for Clients with Neurocognitive Disorder

Answer 23

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.

Question 24

General Nursing Care for Clients with Neurocognitive Disorder - what to do for apraxia

Answer 24

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

Question 25

stages of grief (DAB DA grief)

Answer 25

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

Question 26

Normal/healthy grieving –

Answer 26

Usually lasts 6-8 weeks for the acute stage, but complete resolution of the grief response may take years.

Question 27

Dysfunctional/maladaptive grieving

Answer 27

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

Question 28

how is appetite w/ dementia?

Answer 28

appetite usually stays the same w/ dementia

Question 29

depression - what remains intact?

Answer 29

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

Question 30

depression - better or worse as day goes on

Answer 30

no wandering; sxs often improve as the day progresses
retains social inhibitions

Question 31

which pts sundown?

Answer 31

ask about diurnal pattern - ppl w/ dementia usually sundown. the opposite is usually true w/ depression.

Question 32

does dementia cause paranoia?

Answer 32

no, this would be delirium

Question 33

Lewy bodies - what makes it worse?

Answer 33

.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.

Question 34

lewy bodies - symptoms (lewy gets dizzy when he sleepwalks)

Answer 34

orthostatic hypotension and REM sleep disorders - sleep walkers seen in Parkinson’s and lewy body***

Question 35

MMSE - points

Answer 35

• total of 30 points . 25 or greater is normal, 19 - 24 - mild, 10 - 18 - moderate, 9 or below is severe.

Question 36

interventions for delusions/confusion resulting in agitation:

Answer 36

validate pt’s feelings and gently redirect/distract pt to something else.

Question 37

delirium - what drugs to use (hal and atty have delirium)

Answer 37

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.

Question 38

REM sleep disorder

Answer 38

lewy body & parkinson’s

Question 39

beta amyloids

Answer 39

alzheimers

Question 40

esnophils

Answer 40

lewy body