Nurb Test 1: Delirium and Dementia Flashcards
-progressive loss of consciousness
- Dementia
Cognitive Problems
Three most common in adults
dementia
delirium
depression
- Often associated with dementia and delirium
- Depression
—acute confusion, rapid, can be reversed
- Delirium
- State of temporary but acute mental confusion, always secondary to another condition
- Highest in hospitalized older adults, 40% in icu
- sudden cognitive impairment, disorientation, sensory
Delirium
: Lung, Heart, Infection, Poor nutrition, Drug interactions
delirium Co morbidities
: Longer hospitalization, frequent high misdiagnosis leading to high death rate, further functional decline, Institutionalization
delirium Risk for
misunderstood Rarely caused by a single factor
- Chronic stress, Cholinergic deficiency, Excesses relief of dopamine - Often caused by an underlying factor usually precipitating event happens
delirium Contributors:
A. Demographics: 65 or older, male
B. Cognitive status: dementia, cognitive impairment, and hx of delirium
C. Environmental: admit to icu, use of physical restraints, pain= become aggressive, emotional stress, sleep deprivation
D. Functional: immobility, hx of falls
E. Sensory: overload, deprivation
F. Decreased oral intake: dehydration, malnutrition
G. Drugs- 4 or more, sedatives, opiates, drug interactions, alcohol, drug withdraw
H. Surgery
I. Co-existing medical conditions: acute or terminal illness, hx of stroke, infection or sepsis, or any neurological disease
Delirium Precipitating Factors
- two to three days, rapid
Delirium Clinical Manifestations
Onset
- can last 1-7 days, can be discharged with
delirium Duration
- after two to three days, agitation, misperception, hallucinations
Later sx delirium
-Irritability, restless, confused, can’t concentrate
early sx delirium
- Medical history: family can provide
- Physical exam
- Psychological history
- Medications: new ones put on
- Cognitive measures: mmse: mini mental state examination= what cows drink
- Laboratory tests: electrolytes, bun, creatinine,
- Any preexisting: drug and alcohol levels, liver analysis
Delirium Diagnostic Studies
- When did the confusion begin?
- Does the condition change over a 24-hour period?
- Is there a change in the person’s sleep patterns?
- What specific thought problems have been noticed?
- Is there a history of mental illness or similar thought disturbance?
- Has there been a sudden decline in physical function or a new onset of falls?
Delirium Critical Questions to ask the patient
prevent , early recognition, treatment as necessary
- Focus on eliminating precipitating factors: protect from harm no falls, encourage family to stay at bedside and be involved
- If secondary to infection, antibiotic therapy is started
- Reorientation and behavioral interventions—used in all patients: create safe enviro, don’t overstimulate, reassure the patient and family, pay attention to noise level
- Safety is number one!
Delirium Nursing Management
Nurse’s role:
Delirium Drug Therapy- Reserved for those patients with severe agitation
low dose antipsychotics
short acting benzodiazepine
B. Short-acting benzodiazepines
- lorazepam [Ativan]
A. Treated with low-dose antipsychotics
- Haloperidol (Haldol) 2. Risperidone (Risperdal) 3. Olanzapine (Zyprexa) 4. Quetiapine (Seroquel)
- irreversible, not caused by any other disorder
- Vascular dementia (VD) 20% (multiinfarct)
- Alzheimer’s disease (AD) 60%
A. Primary dementia
due to another condition can reverse if find the cause, if they keep being exposed (prolonged) to these it can make it irreversible
Ex: AIDS dementia complex, Korsakoff’s syndrome=vit B deficiency associated with heavy alcohol consumption, infection
B. Secondary dementia
- Onset of depends on cause
- gradual and progressive
- abrupt step by step pattern
- Etiology of difficult to distinguish based on symptoms alone
Dementia Assessment Clinical Manifestations
Neurological
Vascular
function normal, can do adls, do have memory loss, mild disorientation, words become difficult to find, difficulty with numbers, lose interest in hobbies -still with it enough can compensate, hard to diagnose, ongoing eval
mild dementia
start to lose recognition of family and friends, agitated, pace, wonder get lost more frequently, loss of ability to do skills, argue easily, hallucinations occur
moderate dementia
little memory left, don’t recognize self in the mirror, cant process new info, cant process words, eating and swallowing is difficult, repeat words, can’t perform and adls, become immobile and incontinent
severe dementia
- Try to find cause to see if it is irreversible
- Thoroughly evaluate patient history-anything can treat
- Physical examination to rule out other medical conditions
- Screening
- Mental status testing (MMSE)
- Functional Screening
- Depression screening because it happens with dementia a lot : look at if fatigued, how active are they, appear to be very sad, difficulty concentrating or thinking
- Do an ongoing assessment, find pt is at risk= monitor closely do mri and ct to see changes
dementia dx studies
A. =basic adls, bathing dressing, toileting, eating,
katz
=more complex adls: grocery shopping, cleaning house, cooking, paying bills
lawtons
scores the functions of eating dressing, habit changes
C. Blessed Dementia rating scale:
-Exact is unknown what triggers
-Similar to other forms of dementia, hard to distinguish
-Age is most important risk factor
Early onset= less than 60 years old
Alzheimer’s Disease Etiology
: in genes, earlier onset, more rapid
Familial Alzheimer’s disease
Not in genes
-Sporadic Alzheimer’s:
-Pathologic changes precede clinical manifestations by 5 to 20 years, brain is changing but no signs and symptoms
-Changes in brain structure and function
A. Amyloid plaques: plaques dev as we age, more than norm in hippocampus= short term memories are
B. Neurofibrillary tangles: twisted proteins in the nerves
C. Loss of connections between cells and cell death: parts of your brain
Alzheimer’s Disease Pathophysiology
- Diagnosis of exclusion
-No single clinical test
-Made once all other possible conditions causing cognitive impairment have been ruled out
-Comprehensive patient evaluation: Complete health history, Physical examination, Neurologic assessment, Mental status assessment, Laboratory tests
-Brain imaging tests
CT – Computed Tomography
MRI – Magnetic Resonance Imaging
PET – Positron Emission Tomography- active cells are yellow
*Allow monitoring in early stages and treatment response
Alzheimer’s Disease Diagnostic Studies
: No cure
-Collaborative management aimed at improving or controlling decline in cognition, Controlling undesirable behavioral manifestations
Alzheimer’s Disease Collaborative Care
- Used to treat mild and moderate dementia
- Block enzyme responsible for breaking down acetylcholine
- Improves or stabilizes cognitive decline but does not cure or reverse
Cholinesterase inhibitors
gastric=nausea, vomiting, diarrhea, weight loss, tired drowsy, bleeding, seizures and chest pain
Ex: Meds used to treat mild to moderate: aricept, exelon, cognex
side effects
cholinesterase inhibitiors
cholinesterase inhibitors
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
Tacrine (Cognex)
Manage acute episodes of agitation, Aggressive behavior, Psychosis
-Side effects: extra pyramidial=tremors
Conventional antipsychotic drugs-
conventional antipsychotic drugs
haldol
- More commonly used= less side effects
- Side effects and uncertain benefits
- Atypical antipsychotic drug
atypical antipsychotic drugs
Risperdaol, Zyprexa ,
Seroqual
Alzheimer’s Disease Drug Therapy Depression
ssri
antiseizure
1–help to sleep
. selective serotonin reuptake inhibitors
ssri
prozac, selexa
2-Manage behavioral problems, Stabilize mood
* treating depression can improve their cognitive ability
. Antiseizure drugs
antiseizure drugs
Depakin and tegrteol
- 2,000 IU/day -Slows disease
- -Debatable, some concerns that it causes bleeding
- – Unproven Anti inflammatory action, Thought to slow disease process, se: bleeding
- Hormone Replacement Therapy
Alzheimer’s Disease OTC Drug Therapy
Vitamin E
Gingko biloba
NSAIDS
- Past health history: stroke family history
- Medications-decrease symptoms
- Health perception
- Nutritional State= difficulty eating properly
- eliminating properly: incontinence
- sleep rest pattern: insomnia
- Cognitive perceptual state: forgetful, withdrawn
Alzheimer’s Disease Nursing Assessment
1. Subjective data
- Disheveled appearance
- Mini-Cog, Mini Mental Status Exam
- Neurologic
alzheimers objective data
disoriented to date an time
early
alzheimers
inability to perform simple tasks
middle alzheimers
unable to do adls or self care
late alzheimers
- -Maintain functional ability as long as possible
- Maintain safe environment= prevent falls
- Personal care needs met
- Dignity maintained
Alzheimer’s Disease Planning
Overall goals for patient
- Reduce caregiver stress
- Maintain personal, emotional, and physical health
- Cope with long-term effects associated with caregiving, progress the more they depend on the caregiver
Overall goals for caregiver
alzheimers
- Physical exercise- keep active and involved
- Mental exercise
Ex: Ballroom dancing, Learning new language, Board games, Crossword puzzles, Playing a musical instrument, Reading - Pay attention: One task at a time
- Organize: notebooks for important info, to do list, post it notes, calendars, planners
- Mentally connect new information with other meaningful things: names, songs,
- Laugh and exercise- oxygenates blood
- Drink plenty of water
- Don’t smoke
- Sleep
Preservation of Cognitive Function
Cantaloupe, Blueberries, Sweet Potatoes, Asparagus, Watermelon, Strawberries, Cherries, Tomatoes, Red cabbage, Radishes, Poly unsaturated oils, Oily fish: mackerel/salmon, Vitamin B
Foods Help Memory-
- Antioxidants may be of benefit
- Promote safety in physical activities and driving
- Recognize and treat depression= can cause cog function to increase*
Alzheimer’s Disease Nursing Interventions
- Diagnosis traumatic for patient and family
- Patient often responds with Depression, Denial, Anxiety and fear, Isolation
- Nurse should assess for depression and suicidal ideation
- Counseling and antidepressants may be indicated
- Family members may be in denial, delaying critical early care
- Nurse should also assess family members and their ability to cope and accept diagnosis: can delay treatment
- Ongoing monitoring important
- Work in collaboration with patient’s caregiver
- Teach caregiver how to manage care
- patients subject to other health care problems like uti, falls, pneumonia, adverse effects of medications: caregiver and nurse will notice most of the time the pt won’t
- Change enviro to hospital can cause delirium
Alzheimer’s Disease Acute Intervention
- Most patients cared for in their home
- Assess support system because they take on the care
- Various facilities should be evaluated look at stage of disease, later stage needs more care
- In early stages memory aids may provide benefit: notes, reminders, pictures meaning
- Drugs must be taken regularly, caregiver responsible bc pt doesn’t remember
- Adult day care- gives caregiver a break, provides stimulation
- Demands on caregiver can exceed resources when total care is needed, keep assessing
- Person may need to be placed in a long-term care facility
- Special units for patients are growing in long-term care facilities
- Emphasis on safety
Alzheimer’s Disease Ambulatory and Home Care
-Help to shift mood, help manage stress induced agitation, stimulate positive interactions, facilitate cognitive function, Coordinate motor movements= Rhythmic responses require little mental processing.
-Influenced by the motor center of the brain that responds directly to auditory rhythmic cues.
-Remains intact late into the disease process
-Selections from the individual’s young adult years are likely to have the strongest responses
Early stages pick unfamiliar music
Late stages pick music from early childhood
Adjunct Therapies Music Therapy
-Percussive sounds and fairly quick tempos, tends to naturally promote movement, such as toe taps
Stimulative Music”
”-Assist with activities of daily living: Mealtime to rouse individuals who tend to fall asleep, During bathing to facilitate movement from one room to another
Slightly Stimulative Music
quiets-Ballads and lullabies= relaxation, Include unaccented beats, no syncopation, slow tempos, and little percussive sound. Preparing for bed or any change in routine that might cause agitation.
Sedative music”
- Used more in long term facilities helps spark memoires, encourages verbalization, promotes self-esteem
- Environment: important, dedicated space and time
9: 30 am to 11:30 am or after lunch - higher cognitive functioning - Eliminate background noise=to hold concentration
- Maintain eye contact= to hold concentration
- Choose pictures carefully: sketchpad, Large, colorful pictures, brightly colored markers
- More unrealistic pictures the better it is for the patient
- Only open-ended questions : “What should we call the person?” “Where are they going?” “What is going on here?”
Adjunct Therapies STORYTELLING
- Occur in 90% of patients
- These problems include Repetitiveness, Delusions, Illusions, Hallucinations, agitation, resisting care, wandering
- Are a patient’s way of responding to precipitating factor Pain, Frustration, Temperature extremes, Anxiety
- Nursing strategies to address difficult behaviors: Redirection, Distraction, Reassurance
- Do not threaten or restrain patient if frustrated
- redirect the patient to what time it is and the activities for the day that will actually happen
Alzheimer’s Disease Behavioral Problems
- Verbally abusive or threatening
- Physically threatening, i.e. kicking or pinching
- Overreacting to a situation, or a very minor setback or criticism.
- Causes include: Feeling threatened or humiliated, Frustration, not being understood, lack of self-control, decrease awareness of the rules
Aggressive Behavior
Don’t take it personally, Identify triggers, stay calm and keep self-separated from the argument, don’t show your anxious will cause them to be b=more aggressive, give space, distract their attention, take care of issue without restraint, call for assistance if needed
Dealing with Aggression:
- can occur in delirium or dementia, circadian rhythms are off
- Patient becomes more confused and agitated in late afternoon or evening, Cause is unclear, Remain calm and avoid confrontation
- Can start yelling, resist, wandering
Sundowning
: Create a quiet, calm environment, Maximize exposure to daylight, Evaluate medications, Limit naps and caffeine, Consult health care provider on drug therapy, Familiar attendant – family help reorient
Nursing interventions sundowning
-Injury from falls, Ingesting dangerous substances, Wandering, Injury to others and self, Fire or burns
Alzheimer’s Disease Safety Risks
Home safety check, family education, Supervision, register with Safe Return (government funded program a picture of patient is sent to the local emergency response, if someone calls and says they are lost and helps them to find)
interventions for safety risk
- Pain should be recognized and treated promptly/ assess frequently
- Monitor patient’s response
- Patients can have difficulty communicating complaints
- May exhibit changes in behavior
Alzheimer’s Disease Pain Management
- Under nutrition problem in middle and late stages, don’t like to eat lose interest (long term care facility big thing-hard b/c decreased staff)
- Quiet and unhurried environment
- Easy-grip utensils
- Offer liquids frequently
- Thicken liquid if trouble swallowing, soft food
- Finger foods may allow self-feeding-function at highest ability
- gastric tube (ng, peg) short term solution
Alzheimer’s Disease Eating and Swallowing Difficulties
- In late stages patient will be unable to perform
- Dental problems likely to occur
- Patient may pocket food (stick in cheek), adding to potential tooth decay and abscess=discomfort to aggression
- Inspect mouth regularly, and mouth care should be provided
Alzheimer’s Disease Oral Care
-prompt evaluation and treatment
Urinary tract infection- bc don’t go to bathroom hold or can’t get to it
Pneumonia-can’t move, swallowing problems=aspiration
Death by sepsis
Alzheimer’s Disease Infection Prevention
- In late stages patient at risk for skin breakdown -immobility
- Tend to rashes, areas of redness
- Keep skin dry and clean
- Change patient’s position regularly, assess regularly
Alzheimer’s Disease Skin Care Elimination Problems
-disrupts all aspects of personal and family life
-Very stressful-role reversal child take care of parent
-Caregivers also exhibit adverse consequences
-Work with caregiver to
Assess stressors
Identify coping strategies
Find a support group – local alzheimer’s association chapter
Alzheimer’s Disease Caregiver Support
- Functions at highest level of cognitive ability
- Performs self-care, bathing, dressing, and toileting with assistance as needed
- Experiences no injury
- Uses assistive devices appropriately for ambulation support
- Uses effective coping strategies to manage grief related to diagnosis of
- Verbalizes reality of health situation
- Remains in restricted area during ambulation and activity-prevent injury, don’t want wandering and getting lost
Alzheimer’s Disease Evaluation Patient goals
second most common, protein deposits in the nerve cells brain in areas of thinking, memory, and movement
-Cause is unkown, goes unrecognized bc its hard to dx
Tx-no standard
Nursing care- same as dementia
Lewy Body Dementia-
Dementia plus two of the following indicates a possible diagnosis
-Extrapyramidal signs such as bradykinesia, rigidity, and postural instability, but not
always a tremor
Fluctuating cognitive ability, sleep disturbances
Hallucinations
lewy body dementia sx
Rare and fatal brain disorder, Caused by a prion protein
Earliest symptoms: memory impairment, behavior changes
-Disease progresses rapidly -mentor deterioration, involuntary movement, weakness in the limbs, lead to blindness, then coma
-No diagnosis or treatment
Creutzfeldt-Jakob disease (CJD)-
Type of frontotemporal dementia, Rare brain disorder
Major distinguishing characteristic is marked symmetric lobar atrophy of temporal and/or frontal lobes, shrink
Pick’s disease-
Sx: disturbance in behavior, sleep, personality, then memory loss
-Relentless progression-can’t stop it
picks disease sx
Uncommon disorder, obstruction of flow of cerebral spinal fluid/ Meningitis, encephalitis, or head injury may cause condition
- If diagnosed early, disease is treatable by surgery place a shunt=can’t get memory back
Normal-pressure hydrocephalus-
Symptoms: dementia, urinary incontinence, difficulty walking=unsteady balance, constant headache
normal-pressure hydrocephalus sx
