Neurocognitive lecture Flashcards
What is a neurocognitive disorder
Disturbances in
* Orientation
* Perception
* Memory
* Intellect
* Judgement
* Affect
Resulting in brain dysfunction
What are some effects of Neurocognitive disorders
- Cannot understand facts
- Cannot connect appropriate feelings to events
- Results in inability to meet challenges of living (ADL)
Three main categories of neurocognitive disorders
- Delirium
- Dementia
- Mild neurocognitive disorder
Normal aging
- Some mild degree of forgetfulness is normal
- Mild cognitive impairment does not always progress to severe cognitive impairments
- Does not interfere with a person’s social or occupational behavior
- Memory complaints are more related to depression vs normal aging
- Intellectual function, capacity for change and productive engagement remain stable
Pseudodementia
Treatable disorders, that mimic dementia, usually depression
Possible causes of delirium
- Restraints
- HAC (Alcohol induced)
- Falls
- Sleep deprivation
- Aspiration
- Pneumonia
- Pressure ulcers
- Insufficent food intake
- Drugs
- Hypoglycemia
- Fever
*
Pt with delirium from drug withdrawl are at increased risk for seizures
Morbidity of delirium
Some fail to recover, can worsen over time to a stupor, dementia, coma, death
Complications of delirium
Increase risk for complications
* Falls
* Malnutrition
* decubiti
* Aspiration pneumonia
* Prolonged hospitalization
Decubiti
Pressure ulcers
S+S Delirium
- Disorientation and confusion that fluctuates (Also sundowning)
- Decreased LOC, looks scared
*Acute onset - Last hours to weeks
- Reversible if diagnosed and treated (Can lead to further exasperation if not)
- Disruption of sleep wake cycle (Sundowning)
- Disturbed psychomotor behavior (Agitation, purposeless movement to catatonic stupor)
- Disorientation, incoherent memory disturbances
- Altered perception in forms of illusions, hallucinations and delusions
- Alterations in thinking, disorganized, irrational, delusions
- Hypervigilant, to stupor or semi coma
- Autonomic instability (Tachycardia, sweating, flushed face, dilated pupils, elevated BP)
Is delirium a primary or secondary medical condition
it’s always secondary to a medical condition
Causes of delirium: D
Drugs
Causes of delirium: E
Electrolyte imbalances (Dehydration)
Causes of delirium: L
Lack of drugs
* Withdrawal, pain
Causes of delirium: I
Infection
* Uti or pneumonia
* Syphilis
* Meningitis
Causes of delirium: R
Reduced sensory input
* Hearing or vision deficits
Causes of delirium: I
Intracranial
* CVA
* Subdural hemorrhage
Causes of delirium: U
- Urinary retention/fecal impaction
Causes of delirium: M
Myocardial/pulmonary
Lab analysis for delirium
- Urine analysis (UTI)
- Liver enzymes
- Glucose test
- Electrolytes
- Thyroid test
- Vitamin B12
- Drug and alc test
- Rapid plasma reagin for syphilis
- HIV testing
- CT and MRI (CVA)
- Lumbar puncture (Meningitis)
- PET scan
Population most affected by delerium
Older adults
How long does delirium last
1 week to one month
Depending on underlying cause and age
Does delirium have permanent damage
Yes if left untreated, however if the underlying condition is treated then a complete recovery should occur
Delirium safety assessment
- Pt wants to pull out IV, and cath
- Falling out of bed
Delirium comfort assessment
Sensory input is impaired, need to assess for pain, cold and positioning
Autonomic S+S of delirium
- INcreased vitals
- Tachycardia
- Sweating
- Flushed face
- Dilated pupils
- elevated BP
Delirium Assessment: Physical
- Safety
- Comfort
- Vitals
- Drug reactions or interactions
- Electrolyte disturbances
- Sleep wake disturbances
- Infection (Done by provider)
Gold standard treatment for delirium
Prevention and early mgmt
Nursing interventions for delirium
- Early mgmt and prevention
- Neuro checks regularly
- Safety
- Fall prevention/ prevent injury
- Determine underlying cause
- Electrolyte balance
- Hydration and nutrition
- Turn and position Q2hr
- Therapeutic milieu environment
- Introduce self and call pt by name (Reorientated)
- Hallucinations: enforce reality
- One piece of info at a time, short concrete sentences
- make sure pt wears glasses and hearing aids
- Reorientated (Clocks, calendars, well lit room, family pictures)
- Educate and include family
Dementia etiology
- Interaction between genes, lifestyle and environment
- Not a specific disease but a group a symptoms that can be caused by many different diseases
- Different categories of dementia have different etiologies but a similar clinical picture
- This is beyond the normal effects of aging
Dementia onset
Over months, not sudden
Dementia causes
- Alzheimer’s
- Vascular disease
- HIV
- Alcoholism
Dementia alterations in consciousness
None
Dementia mood/affect
Flat and or delusional
Dementia speech
Incoherent, slow speech
Is dementia reversible
No
Dementia memory
Impaired memory and judgment
Delirium Onset
Sudden: Hours to days
Delirium consciousness
Altered level of consciousness
Delirium mood/ affect
Labile mood, swinging
Delirium: Speech
Incoherent RAPID speech
Delirium memory
Impaired memory or judgment
Alzheimer’s disease
- Most common cause of dementia
- Mixed pathologies ( Can occur with other forms of dementia (Lewy- body or CVD))
- Early clinical symptoms
- Late clinical symptoms
Alzheimer’s disease: Early symptoms
- Memory impairment
- Apathy
- Depression
Alzheimer’s disease: Late symptoms
- Impaired communication
- Poor judgment
- Physical impairment
Vascular dementia
- Occurs from cerebral blood vessel dmg (Stroke)
- Ischemic or hemorrhagic processes
- More common as mixed pathology (Not the only one)
*** Cognitive and motor function impairment **
Initial symptom of vascular dementia
- Impaired executive functioning (Task management and higher level thinking)
Lewy body dementia
- Abnormal aggregations of proteins
- Develops in the cortex
- similar S+S to alzheimer’s
- Visuospatial impairment
- Occurs with parkinson’s disease
What protein is abnormal in lewy body dementia
Alpha-synuclein
Early S+S lewy body dementia
Sleep disturbances
Frontotemporal lobar degeneration (FTLD)
- Early symptoms
- Memory is typically spared in early changes
- Atrophy of frontal and temporal lobes
- Abnormal protein inclusions
- Earlier age of onset
Early symptoms of Frontotemporal lobar degeneration (FTLD)
Behavioral changes
TBI related dementia
- Occurs secondary to a tbi, from brain rattling around
- Depending on severity of TBI symptoms may eventually subside or may be perm
dementia pugilistica-syndrome
TBI based dementia, caused by repeated injury
Characterized by
* Emotional instability
* Dysarthria
* Ataxia
* Impulsivity
Chronic traumatic encephalopathy
Injury to frontal lobe and poor impulse control
Nursing assessment dementia
- Safety (Home environment, general)
- PLan with family how mgmt labile moods, aggressive behavior, nocturnal delirium catastrophic reactions
- Eval for suicide or aggression
- Review meds including over the counter
- Asses for evidence of abuse or neglect
Agraphia
S+S dementia
Inability to read or write
Hyperorality
S+S of dementia
Need to taste, chew and place objects in one’s mouth
Hypermetamorphosis
S+S dementia
Touching everything that one can see
Hallucinations and delusions interventions
- Minimize focus on delusional thinking
- Reassure them they ar esafe
- Never argue
- DO not ignore reports of hallucinations: what they perceive is real to them and they can be disturbed by them (May need anti psych meds)
- Assess for med side effects
- Ensure hearing aids and glasses are available and working
- Distraction techniques
- Assess if hallucinations are problematic for pt
Risk for injury: Dementia
- Pt wants to pull out iV, foley, feeds
- Wandering
- Falling
- Pressure injuries (From immobility)
- Skin integrity
Pt care: Dementia
- Food and fluid intake monitoring
- Monitor electrolytes
- Vitals
- Assistive devices
- Weigh pt weekly
- Offer finger foods
- Ensure safety of solid foods (Avoid hard candy, popcorn nuts)
- Dysphagia can occur try pureed foods or ensure or decision about tube feeding
Non pharm interventions: Dementia
- Reduce physical and chemical restraints
- mgmt of pain
- provide sensory stimulation activities and socialization
- improve communication
- Hearing aids and glasses
- Regular toileting
- relaxation strategies, massage
- outdoor opportunities
Non pharm interventions: Dementia, memory enhancement
- Reinforce short and long term memory
- Remind pt what they had for breakfast and what activities recently occured
- Fill in blanks casually when memory falters
- Encourage story telling of earlier years
Pharm interventions for dementia: Cholinesterase inhibitors
- FDA approved for alzheimer’s (AD)
- Lessens impairment in cognition, behavior and function in ADL as disease process advances
- Makes more Acetylcholine available by inhibiting breakdown, stimulates nicotinic receptors to make more Ach
- Mild to moderate AD
- Some efficacy in lewy body dementia
Cholinesterase inhibitor: drug names
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Cholinesterase inhibitor: Side effects
- Effects are time limited
- GI disturbances (N+V+D, increased gastric upset=risk for ulcers)
- Take with food to minimize GI upset
- Sedation and weight gain are Unusual
- Rare effects is it worsening asthma
- Lethal in overdose
Memantine (Namenda)
“Artificial magnesium” , known as a cognitive enhancer
* NMDA- glutamatergic ion channel antagonist
* Blocks over secretion of glutamate
- FDA approved for use during MODERATE to SEVERE stages of AD
- Does not stop or reverse effect of disease, just slows progression
Memantine (Namenda): SE
- Dizziness, HA, constipation
Antidepressants in Dementia
- Well tolerated in older pt (used in much lower doses)
- Treats depression symptoms and anxiety
- Need to avoid meds with anticholinergic side effects (Like TCA)
- Older pt are at higher risk of anticholinergic tox
Trazodone
Antidepressant used to treat insomnia
Atypical antipsychotics in dementia
- NOT indicated for used in dementia
- Increased risk of for stroke in elderly dementia pt
- Black box warnings associated with increased risk of death in elderly pt who display psych behaviors (Cardio relate)
- Limited use only
- Behavioral interventions preferred
