Neurocognitive Disorders Flashcards
Delirium
Disturbance in attention and awareness
- acute onset (h-d)
- change in baseline fluctuating with lucidity over 24h-d
Symptoms of delirium
May have poor long-term memory, disorientation (often only oriented to self), visuospatial ability, delusions and hallucination (often visual), often sus and persecutory prob, sleep/wake (reversed, no sleep)
Physio causes of delirium
- meds (BDZs)
- infx
- F&E chx
- hypoxia/ischemia
- surgery
- brain chx—dec cerebral fun or brain metab, inc plasma cortisol, NT imbalance, damage enzymes sys, BBB, cell membranes
- kids—often meds or fever
Cardinal features of delirium
- acute onset and fluc course
- Dec ability to direct, focus, shift, sustain attn
- disorg thinking
- disturbance of consciousness
Assessment of delirium
- cardinal features
- cog and perceptual disturbance—illusion, hallucination
- physical needs—help with ADLs
Nursing outcomes of delirium
- safety
- orientation
- visual cues in enviro to orient
- free from falls
- pt/fam understand illness cause
- continuity of care providers
Non-pharm tx for delirium
- express fears and discomfort
- comfort measures for trust
- freq verbal orientation
- freq brief interactions
- consistent nursing staff
- tv in day, off in night
- nonverbal music
- slowly approach pt and call name
- good lighting
- easy to read clock/calendar
- Dec stim at night
- Dec sleep disruptions, lower lights
- provide physical safety
- sx and supportive care (hydrate, nut, pain control, reassurance)
Pharm tx for delirium
- very small dose of antipsychotics PRN
- BDZs—watch for opp fx of agitation; better if hepatic probs
- sleep—-mirtazapine
- objective pain control; consider intermittent narcotics
- ID drug-drug interactions
- tx underlying causes
Communication with delirious pts
- short simple sentences
- speak low
- ID self AAT and explain process
- repeat questions if needed and leave time for response
- educate pt when not conf and fam
- call by name
- repeat PRN
- tell what to do, not what NOT to do
- express fears
- brief freq verbal orientation
dementia
degen, prog neuropsych dx resulting in cog, emo, bx, phys and dec fxn then death
Neurocog dx
Umbrella term including dementia
- prog dec of cog fxn and global impairment of intellect
- no LOC change
- acquired; not dev
- prob with memory, prob solving, complex attn, orientation, vocab, math, thinking abstractly
Mild neurocog dx
No interference with ADLs
Major neurocog dx
Interfere with daily fxn and ind
- examples Alz, vascular dementia, TBI, Parkinson’s, HIV, Hunt’s
Alzheimer’s
- most common dementia
- type of dementia that disturbs executive functions and is irreversible and progressive
- often dx with r/o
Symptoms of Alz
- aphasia—lose lang (receptive and expressive)
- apraxia—lose purposeful mvt
- agnosia—lose ability to recognize object/ppl - can’t remember family (measure with MMSE)
- sundown in
- confabulation—make things up to inc self-esteem
- perseveration—repetition of words, phases, gestures
- hyperorality—put things in mouth to taste and chew
Epidemiology of Alz
- age 65+ and family
- CVD
- social engagement
- diet
- TBI
- head injury
- HTN and dyslipidemia
Bio rf for Alz
Oxidative stress and free radicals precedes plaques
- inflammation after stroke (use of NSAIDs may Dec)
Patho of Alz
- Extracellular sticky beta-amyloid plaques (block synapses that are normally protected by tau proteins so nutrition can’t get into the cells and cells starve)
- Intracellular neurofibrillary tangles—abnormal collections of tau proteins
- brain atrophy and increase ventricle size
- oxidative stress and free radicals
- inflammation
NTs in Alz
- ACh (parasymp)—learn, memory, mood; prod decreases as disease progresses
- Glutamate—cell signaling, learning, memory; inc in Alz (NMDA antags dec Ca by blocking NMDAr)
Priorities for Alz tx
- initial delay cog decline
- moderate - protect pt from hurting self
- late - phys needs become the focus of care
Mild Alz sx
- forgetful, misplaced stuff, Dec recall, social w/d, self-frustration
- change might not be apparent except to spouse
Mod Alz sx
- Dec self-care, disoriented to time/place, wander, pace, delusions, hallucinations, Dec visual perception
- accidents, need supervision, emotional mood swing
- sx noticeable
Severe Alz sx
- often LTC
- emotional self-care, long-term memory loss, lose language
- incontinence, gait probs, mute, sz, can’t feed self
- physical needs important
Dementia assessment
- biological—phys and ROS
- phys fxn—sleep-wake, self-care, pain, nut, activity
- psych—confab, perseveration, agraphia, hyperorality, aphasia, apraxia, agnosia, sundowning, sus, delus/halluc, illusions, anx, mood chx, catastrophic rxn
- defense mechs—denial, confab, perseveration, avoidance
- social—fxn, social sys, spiritual, QoL, primary caregiver, legal status
- bx
Behavioral s/s dementia
- apathy and w/d
- restless, agitate, agg
- aberrant motor bx
- disinhibition
- hypersexuality
- signs stress/anx
Dementia dx
- r/o metabolic dx
- CT, PET, med, psych hx
- MMSE
- often only known in autopsy
- review recent sx, meds, nut
Interventions for confusion/agitation
- speak clear, slow, direct
- approach from front
- face pt
- 1 task at a time
- patience!
- nutrition—watch wt, intake, hydrate, watch for swallow prob
- bowel/bladder fxn
- para and nonverbal comm
- walk if pt restless
- pictures of pets, fam, wildlife
- music they like (when young)
- self-care but allow ind
- sleep intx
- balance activity with sleep
- relax techniques
- pain measures—don’t rely on verbalizing pain
Acetylcholinesterase inhibitors
- Galantamine for mild-mod
- Donepezil and rivastigmine or transdermal patch (all stages)
- used to delay not dec cog decline (stabilize memory, lang, orientation)
- peak in 3M but continues to delay decline
- minimal benefit after 1 year
Benefit of the patch
Fewer GI prob
Most common side effects of AChEI
N/V
- CNS dizzy, HA
- GI
- insomnia
- brady and syncope
NMDAr anatgonist
Memantine
- restore fxn of damaged nerve cells and dec abnormal excitatory signals of the NT glut
- slow decline, slight inc in cog fxn
- used in all stages Alz and vasc dementia (mod-severe)
- block glut from NMDAr–prevent Ca from going into cells (NMDA normally binds and causes Ca to go into cell–dec abnormal signal of glut)
NMDA antag SE
dizzy, confusion, HA, constipation
Order of Alz meds
- 1st ACh
- 2nd NMDAr antag
- can give both at once
Off label meds for Alz
Start very low dose
- antipsychotics (may inc mort; be cautious)
- antidepressants
- antianx
- anticonvulsants
