Problems r/t Neurocognitive Disorders

Question 1

Delirium

✣ disturbance in attn & awareness
✣ change in cognition
✣ diff sustaining & shifting attn
✣ extremely distractible
✣ disorganized thinking prevails

Answer 1

✣ rambling speech, irrelevant, pressured, incoherent
✣ disorientation to time & place
✣ emotional instability
✣ hallucinations/illusions
✣ sleep-wake cycle dist
✣ fluctuating psychomotor activity

Question 2

Autonomic manifestations of Delirium

✣ tachycardia
✣ sweating
✣ flushed face
✣ dilated pupils
✣ elevated BP

Question 3

Predisposing Factors of Delirium

✣ Systemic infections
✣ Hepatic or renal failure
✣ Febrile illness
✣ Head trauma

Answer 3

✣ Metabolic disorders, like fluid & electrolyte imbalances, hypercarbia, or hypoglycemia
✣ Seizures
✣ Hypoxia & COPD
✣ Migraine ha’s

Question 4

✣ Brain abscess or brain neoplasm
✣ Nutritional deficiency
✣ Uncontrolled pain
✣ Burns

Answer 4

✣ Stroke/heat stroke
✣ Orthopedic & cardiac surgeries
✣ Social isolation

Question 5

Other Etiological Implications of Delirium

• Substance Intoxication Delirium & Substance Withdrawal Delirium
  > e.g., alcohol, cannabis, cocaine, inhalants, sedatives, anxiolytics, opioids, hypnotics

Medication-Induced Delirium
> e.g., antihypertensives, anticholinergics, steroids, anticonvulsants, analgesics, anesthetics

Answer 5

• Delirium d/t another medical condition or to multiple etiologies

Question 6

Neurocognitive Disorder (NCD)

• Impairment in the cognitive functions of thinking, reasoning, memory, learning, & speaking
• Mild or major

Answer 6

• Mild NCD - mild cognitive impairment
• Major NCD - can be reversible or progressive

Question 7

Neurocognitive Disorder (NCD)

✩ Primary: Alzheimer’s disease (AD) [most common]

Answer 7

✩ Secondary: c/b or r/t another dz or cond (e.g., HIV, cerebral trauma)

Question 8

Reversible NCD: Temporary (temporary dementia)

• Stroke
• Depression
• S/e of rx’s
• Nutritional deficiencies
• Metabolic disorders

Answer 8

NCD Impairment

! abstract thinking, judgement, & impulse control
! social conduct
! behavior
! personal appearance & hygiene neglected
! possibly lang effects (aphasia)
! personality change
! mood changes
! ability to perform ADL’s, work

In most clients, NCD runs a progressive, irreversible course

Question 9

?

Is the inability to carry out motor activities despite intact motor function

Answer 9

Apraxia

Question 10

Stages of Alzheimer’s Disease

Answer 10

Stage 1

No apparent symptoms

Question 11

Stage 2

Forgetfulness

Answer 11

Stage 3

Mild cognitive decline/disorder

Question 12

Stage 4

Mild-to-moderate cognitive decline

e.g., confabulation occurs

Answer 12

Stage 5

Moderate cognitive decline

Question 13

Stage 6

Moderate-to-severe cognitive decline

e.g., can become incontinent w/urine and/or feces

Answer 13

Stage 7

Severe cognitive decline

e.g., bedfast, aphasic

Question 14

Predisposing Factors of NCD’s: Categories

✶ NCD d/t Alzheimer’s dz
✶ Vascular NCD
✶ Frontotemporal NCD
✶ NCD d/t TBI
✶ NCD d/t Lewy Body dementia
✶ NCD d/t Parkinson’s dz
✶ NCD d/t HIV infection

Answer 14

✶ Substance-induced NCD
✶ NCD d/t Huntington’s dz
✶ NCD d/t prion dz
✶ NCD d/t another medical condition
✶ NCD d/t multiple etiologies
✶ Unspec NCD

Question 15

NCD d/t Alzheimer’s dz

• Onset is slow & insidious
• Progressive & deteriorating
• Memory impairment, behavioral changes
• Mult factors influence development

Answer 15

Possible causative factors:

• Neurotransmitter alterations (e.g., acetylcholine)
• Plaques & tangles (that lead to neuron death)
• Head trauma
• Genetic factors (e.g., familial pattern)

Question 16

Vascular NCD

• Significant cerebrovascular dz
• More abrupt onset than in AD, course is more variable

Answer 16

Directly r/t an interruption of blood flow to the brain
- HTN
- Cerebral emboli
- Cerebral thrombosis

Question 17

Frontotemporal NCD

• Occurs as a result of shrinking of the frontal & temporal anterior lobes of the brain
• Prev called Pick’s dz

Answer 17

• Exact cause is unknown but genetics appears to be a factor

Question 18

NCD d/t TBI

• Amnesia is the most common neurobehavioral sx following head trauma
• Repeated head trauma can result in dementia pugilistica

Answer 18

• Synd characterized by emotional lability, dysarthria, ataxia, & impulsivity

Question 19

NCD d/t Lewy Body Dz

• Similar to AD, but progresses more rapidly
• Appearance of Lewy bodies in the cerebral cortex & brainstem

Answer 19

• Progressive & irreversible
• May account for 25% of all NCD cases

Question 20

NCD d/t Parkinson’s Dz

• Loss of nerve cells located in the substantia nigra
• Decr in dopamine activity

Answer 20

• Cerebral changes in NCD d/t PD sometimes resemble those of AD

Question 21

NCD d/t HIV Infection

• Brain infections w/opportunistic organisms or by the HIV-1 virus directly

Answer 21

• Sx’s may range from barely perceptible changes to acute delirium to profound cognitive impairment

Question 22

Substance-Induced NCD

• NCD can occur as the result of substance reactions, overuse, or abuse
• Alcohol, sedatives, hypnotics, anxiolytics, & inhalants

Answer 22

• Drugs that cause anti-cholingeric s/e’s
• Toxins, like lead & mercury

Question 23

NCD d/t to ?

• This is transmitted as a Mendelian dominant gene
• Damage occurs in the areas of the basal ganglia & the cerebral cortex
• Client usually declines into a profound state of dementia & ataxia

Answer 23

Huntington’s dz

Question 24

NCD d/t prion dz

• Manifestations: problems w/coordination or other movement disturbances along w/rapidly progressing dementia
• 5-15% of cases of prion dz have a genetic component
• Sx’s may develop @ any age in adults, but typ occur between 40-60 yrs

Answer 24

• Clinical course is extremely rapid, w/the progression from diag to death in <2 yrs
• Most common form of prion dz in humans is Creutzfeldt-Jakobs dz

Question 25

NCD d/t Another Medical Condition * Hypothyroidism * Hyperparathyroidism * Pituitary insufficiency * Uremia * Encephalitis * Brain tumor * Pernicious anemia * Thiamine deficiency * MS

Answer 25

* Uncontrolled epilepsy * Cardiopulmonary insufficiency * F&E imbalances * CNS & systemic infections * SLE

Question 26

? A dz c/b a deficiency of nicotinic acid (niacin)

Answer 26

pellagra

Question 27

Patient Assessment: Client History * mood swings, personality, behavior changes, catastrophic emotional reactions * cognitive changes - attention span, thinking process, problem-solving, memory

Answer 27

* language difficulties * orientation to person, place, time, situation * appropriateness of social behavior

Question 28

NCD versus Pseudodementia

Question 29

Physical Assessment * Neurological exam: mental status, alertness, muscle strength, reflexes, sensory perception, language skills, & coordination * Mental status exam in NCD

Answer 29

* Psychological tests - r/o pseudodementia/depression

Question 30

Diagnostic Lab Evaluations Blood & urine tests * Various infections * Hepatic & renal dysfunctions * Diabetes or hypoglycemia * Electrolyte imbalances * Metabolic & endocrine disorders * Nutritional deficiencies * Presence of toxic substances

Answer 30

Other * EEG * CT * PET * MRI * LP to examine CSF

Question 31

Outcome Criteria * Has not experienced physical injury * Has not harmed self or others * Has maintained reality orientation to the best of his or her capability

Answer 31

* Discusses positive aspects about self & life * Participates in ADLs w/assistance

Question 32

Nursing Diagnoses in NCD

Question 33

Risk for Trauma: Goals/Interventions * **Arrange the furniture & other items in the room to accommodate the client's disabilities** * **Keep the lowest position** * **Consider room near nurse's station or 1:1**

Answer 33

* Assist w/ambulation * Decrease stimuli * Remain calm & undemanding * Consider movement therapy and/or use of antipsychotics

Question 34

* Keep the individual on a structured schedule of recreational activities & a strict feeding & toileting schedule * Provide a safe, enclosed space for pacing & wandering

Answer 34

* Walk w/the individual for a while & gently redirect him or her back to the care unit * Ensure that outdoor exits are electronically controlled

Question 35

Disturbed Thought Processes/Impaired Memory & Disturbed Sensory Perception - Goals/Interventions * Try to keep the client as oriented to reality as possible * Use clocks & calendars w/large #'s that are easy to read * Use colorful signs

Answer 35

* Encourage family & close friends to be a part of the client's care * Provide the client w/radio, television, & music if they are diversions the client enjoys * Ensure that noise lvl is controlled to prevent excess stimulation

Question 36

* Reminiscence therapy * Consistency in safe members * Monitor for med s/e's

Answer 36

* Minimize focus on delusional thinking * Provide hearing aid or glasses if usually worn * Reassurance of safety

Question 37

Impaired Verbal Communication - Goals/Interventions * Provide clear, simple one-word direction * Use non-verbal gestures * Approach from front * Consistency in staff

Answer 37

Self-Care Deficit - Goals/Interventions * Simple, structured environment * Provide assistance as needed

Question 38

Patient & Caregiver Education

Answer 38

Treatment Modalities: Delirium * Determine & correct underlying cause * Attend to F&E status, hypoxia, anoxia, & diabetic problems * Remain w/client @ all times, provide orientation & assurance * Low stimuli lvl * Agitation/aggression may require treatment w/rx

Question 39

Treatment Modalities: NCD * Primary consideration = ETIOLOGY * Complete clinical workup to identify syndrome & its causes * General supportive care incl security, stimulation, patience, nutrition

Question 40

Medications in NCD Cognitive impairment: ____ * Donepezil * Rivastigmine * Galantamine

Answer 40

cholinesterase inhibitors

Question 41

NMDA receptor antagonist ____

Answer 41

Memantine (Namenda)

Question 42

Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, wandering = ____ Risperidone Olanzapine Quetiapine Haloperidol Pimavanserin (PD) *Consider anticholinergic effects*

Answer 42

antipsychotics

Question 43

Depression = Antidepressants SSRIs * Sertraline * Paroxetine Tricyclic Antidepressant * Nortriptyline * Trazodone

Question 44

Anxiety = Benzodiazepines * Diazepam * Chlordiazepoxide * Alprazolam * Lorazepam * Oxazepam

Question 45

☆ Antipsychotics in Lewy Body Disease ☆

Answer 45

☆ Understand how Alzheimer's meds work ☆