OA: Cognitive Disorders Flashcards
Concept of cognition
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Mental Status Exam
- oriented x4
- memory
- cognitive function
- thought process
- judgment
- perception
Concepts related to cognition which explain physiological changes in cognition
- oxygenation
- perfusion
- homestasis/regulation (fluid and electrolyte balance; inflammation)
Delirium
new onset of change in cognition, function, or behavior
Clinical manifestations of delirium
- trouble paying attention
- fluctuating levels of consciousness
- patient calm during day, restless at night
- hyper or hypoactive
- disoriented
- illusions
- hallucinations
3 manifestations more unique to delirium than dementia
- trouble paying attention
- fluctuating levels of consciousness
- patient calm during day, restless at night
3 strategies that can be used to understand and assess situations for altered cognition
- mental status exam
- related concepts
- concept of cognition
Settings where delirium likely to occur
- intensive care setting (most likely)
- hospital
- postoperatively
- pts with dementia in hospital
Possible causes of delirium
- surgery
- drugs
- infections (UTI or Pneumonia)
- cerebrovascular dz
- CHF
- hypoglycemia
- fever
- dehydration
- head injury
- environmental changes
- prolonged sleep deprivation
CAM scale
- screens specifically for signs of delirium
- interview-style
- 5 mins
- consists of 2 parts
- accounts and controls for ageism
1st part of CAM scale
screens for overall cognitive impairment
2nd part of CAM scale
screens specifically for traits associated with reversible confusion
CAM is highly effective in _______, but does not _______
identifying delirium
measure severity
Nursing process associated with delirium/dementia
Assessment: CAM scale
Intervention: identify any contributing factors (priority) and maintain patient safety
Alzheimer’s Disease
chronic, progressive, degenerative disease of the brain
most common type of dementia
AD
Dementia
progressive loss of cognitive function that is steady and irreversible
clinical syndrome of cognitive deficits that involves memory impairments and a disturbance of at least one other area of cognition
Dementia affects…
memory, thinking, language, judgment, behavior
aphasia
A language disorder that affects a person’s ability to communicate.
Apraxia
Difficulty with skilled movements even when a person has the ability and desire to do them.
agnosia
inability to interpret sensations and hence to recognize things, typically as a result of brain damage.
Providers only diagnose patients if….
two or more brain functions are significantly impaired and irreversible
Hypotheses-cholinergic
low levels of acetylcholine present
Amyloid plaques
neurofibrillary tangles
-loss of connections between cells and cell death
TAU
TAU proteins become twisted inside nerve cells
Warning signs of AD
- misplacing things
- losing ability to retrace steps
- decreased/poor judgment
- withdrawal from work/social
- changes in mood and personality
- memory loss that disrupts daily life
- challenges in planning and problem solving
- confusion with time and place
- new problems with words in speak and writing
Stages of AD
Seven stages of AD
Reisberg Model
- no impairment
- normal age-related forgetfulness (not noticed by others)
- mild cognitive impairment (noticed)
- mild or early stage AD (withdrawal from social/memory)
- moderate AD (unable to live alone)
- moderate-severe AD (max. assistance with ADLs)
- Severe AD (lose ability to respond and function with out continuous assistance)
Top Risk factors for dementia
- age
- family hx
- genetics
Contributing pathophysiologic processes
- cholinergic hypothesis
- NMDA receptor
NMDA receptor
overstimulated which results in excessive release of glutamate
glutamate
excitatory neurotransmitter
Medications for dementia
- Anti-cholinesterase inhibitors
- NMDA receptor antagonists
- anti-depressants/anti-anxiety agents
- atypical anti-psychotics
Anti-cholinesterase inhibitors
reduce breakdown of acetylcholine
- donepezil
- rivastigmine
NMDA receptor antagonists
limit effects of glutamate
-memantine
anti-depressants/anti-anxiety agents
-may use SSRI; effective for both depression and anxiety
atypical anti-psychotics
used when patients have hallucinations or delusions
-used in lower dosages than with mental illness
- seroquel
- olanzapine
- risperidone
What do you monitor with atypical anti-psychotics?
sedation
Nurse’s role with dementia meds
understand intended effect
-expect OA patient to receive lower dosages of these meds
“Start low, Go slow”
Assessment strategies used on admission for dementia
- MMSE
- MOCA
- Mental status exam
Assessment strategy used on admission for delirium
CAM scale
Daily assessment
- oriented x4
- questions about daily events as tolerated
Questions to ask family
- Challenging behaviors?
- How pt performs ADLs?
- Sleep pattern disrupted?
- Communication problems?
CARES Model
-person-centered approach for any person in any situation at any level of cognitive decline/impairment
C: connect with person A: assess behavior R: respond appropriately E: evaluate what works S: shares with others
Habilitation Tenets
validates emotions, maintains dignity, creates moments for success, uses all of remaining skills
5 tenets of habilitation
- make the physical environ. work
- know communication remains possible
- focus on remaining skills
- live in patient’s world: behavioral changes
- enrich the patient’s life
Physical Environment
- maintain safety
- allow freedom when possible
- take keys away if needed
- may not allow to cook or smoke without supervision
Self care deficits for bathing
- have everything ready in advance
- warm room
- undressing: use distraction
Self care deficits for dressing
- choose specific spot to dress and another to undress
- match items
- simple clothes
- don’t argue to change clothes: distract
Self care deficits for toileting
- schedule visits
- looks for fidgeting or picking at groin
- look for pattern when accidents occur
- adequate lighting
- bedside commode at night
- withhold fluid at night
- big meal at lunch
Problem behaviors
- 90% with AD demonstrate behavior problems
- can lead to caregiver stress
- major factor for nursing home placement
When following the 5 tenents, we….
decrease the number of situations which might provoke patient
Cues to distress
- increased vocals
- agitation
- withdrawal
- changes in function
- recognize and treat promptly
Sundowning
- limit naps and caffeine
- provide safe place for pacing and muttering
- quiet space to watch tv or listen to music
- provide activity when sunsetting
- improve lighting to avoid shadows
ATD model
A: anticipate
T: tolerate
D: do not agitate
