Problems r/t Neurocognitive Disorders Flashcards
* Alzheimer’s Disease * Vascular neurocognitive disorders * Frontotemporal neurocognitive disorder * Lewy body dementia
Delirium
✣ disturbance in attn & awareness
✣ change in cognition
✣ diff sustaining & shifting attn
✣ extremely distractible
✣ disorganized thinking prevails
✣ rambling speech, irrelevant, pressured, incoherent
✣ disorientation to time & place
✣ emotional instability
✣ hallucinations/illusions
✣ sleep-wake cycle dist
✣ fluctuating psychomotor activity
Autonomic manifestations of Delirium
✣ tachycardia
✣ sweating
✣ flushed face
✣ dilated pupils
✣ elevated BP
Predisposing Factors of Delirium
✣ Systemic infections
✣ Hepatic or renal failure
✣ Febrile illness
✣ Head trauma
✣ Metabolic disorders, like fluid & electrolyte imbalances, hypercarbia, or hypoglycemia
✣ Seizures
✣ Hypoxia & COPD
✣ Migraine ha’s
✣ Brain abscess or brain neoplasm
✣ Nutritional deficiency
✣ Uncontrolled pain
✣ Burns
✣ Stroke/heat stroke
✣ Orthopedic & cardiac surgeries
✣ Social isolation
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
- Delirium d/t another medical condition or to multiple etiologies
Neurocognitive Disorder (NCD)
- Impairment in the cognitive functions of thinking, reasoning, memory, learning, & speaking
- Mild or major
- Mild NCD - mild cognitive impairment
- Major NCD - can be reversible or progressive
Neurocognitive Disorder (NCD)
✩ Primary: Alzheimer’s disease (AD) [most common]
✩ Secondary: c/b or r/t another dz or cond (e.g., HIV, cerebral trauma)
Reversible NCD: Temporary (temporary dementia)
- Stroke
- Depression
- S/e of rx’s
- Nutritional deficiencies
- Metabolic disorders
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
?
Is the inability to carry out motor activities despite intact motor function
Apraxia
Stages of Alzheimer’s Disease
Stage 1
No apparent symptoms
Stage 2
Forgetfulness
Stage 3
Mild cognitive decline/disorder
Stage 4
Mild-to-moderate cognitive decline
e.g., confabulation occurs
Stage 5
Moderate cognitive decline
Stage 6
Moderate-to-severe cognitive decline
e.g., can become incontinent w/urine and/or feces
Stage 7
Severe cognitive decline
e.g., bedfast, aphasic
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
✶ 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
NCD d/t Alzheimer’s dz
- Onset is slow & insidious
- Progressive & deteriorating
- Memory impairment, behavioral changes
- Mult factors influence development
Possible causative factors:
- Neurotransmitter alterations (e.g., acetylcholine)
- Plaques & tangles (that lead to neuron death)
- Head trauma
- Genetic factors (e.g., familial pattern)
Vascular NCD
- Significant cerebrovascular dz
- More abrupt onset than in AD, course is more variable
Directly r/t an interruption of blood flow to the brain
- HTN
- Cerebral emboli
- Cerebral thrombosis
Frontotemporal NCD
- Occurs as a result of shrinking of the frontal & temporal anterior lobes of the brain
- Prev called Pick’s dz
- Exact cause is unknown but genetics appears to be a factor
NCD d/t TBI
- Amnesia is the most common neurobehavioral sx following head trauma
- Repeated head trauma can result in dementia pugilistica
- Synd characterized by emotional lability, dysarthria, ataxia, & impulsivity
NCD d/t Lewy Body Dz
- Similar to AD, but progresses more rapidly
- Appearance of Lewy bodies in the cerebral cortex & brainstem
- Progressive & irreversible
- May account for 25% of all NCD cases
NCD d/t Parkinson’s Dz
- Loss of nerve cells located in the substantia nigra
- Decr in dopamine activity
- Cerebral changes in NCD d/t PD sometimes resemble those of AD
NCD d/t HIV Infection
- Brain infections w/opportunistic organisms or by the HIV-1 virus directly
- Sx’s may range from barely perceptible changes to acute delirium to profound cognitive impairment
Substance-Induced NCD
- NCD can occur as the result of substance reactions, overuse, or abuse
- Alcohol, sedatives, hypnotics, anxiolytics, & inhalants
- Drugs that cause anti-cholingeric s/e’s
- Toxins, like lead & mercury
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
Huntington’s dz
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
- 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
NCD d/t Another Medical Condition
- Hypothyroidism
- Hyperparathyroidism
- Pituitary insufficiency
- Uremia
- Encephalitis
- Brain tumor
- Pernicious anemia
- Thiamine deficiency
- MS
- Uncontrolled epilepsy
- Cardiopulmonary insufficiency
- F&E imbalances
- CNS & systemic infections
- SLE
?
A dz c/b a deficiency of nicotinic acid (niacin)
pellagra
Patient Assessment: Client History
- mood swings, personality, behavior changes, catastrophic emotional reactions
- cognitive changes - attention span, thinking process, problem-solving, memory
- language difficulties
- orientation to person, place, time, situation
- appropriateness of social behavior
NCD versus Pseudodementia
Physical Assessment
- Neurological exam: mental status, alertness, muscle strength, reflexes, sensory perception, language skills, & coordination
- Mental status exam in NCD
- Psychological tests - r/o pseudodementia/depression
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
Other
- EEG
- CT
- PET
- MRI
- LP to examine CSF
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
- Discusses positive aspects about self & life
- Participates in ADLs w/assistance
Nursing Diagnoses in NCD
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
- Assist w/ambulation
- Decrease stimuli
- Remain calm & undemanding
- Consider movement therapy and/or use of antipsychotics
- Keep the individual on a structured schedule of recreational activities & a strict feeding & toileting schedule
- Provide a safe, enclosed space for pacing & wandering
- Walk w/the individual for a while & gently redirect him or her back to the care unit
- Ensure that outdoor exits are electronically controlled
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
- 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
- Reminiscence therapy
- Consistency in safe members
- Monitor for med s/e’s
- Minimize focus on delusional thinking
- Provide hearing aid or glasses if usually worn
- Reassurance of safety
Impaired Verbal Communication - Goals/Interventions
- Provide clear, simple one-word direction
- Use non-verbal gestures
- Approach from front
- Consistency in staff
Self-Care Deficit - Goals/Interventions
- Simple, structured environment
- Provide assistance as needed
Patient & Caregiver Education
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
Treatment Modalities: NCD
- Primary consideration = ETIOLOGY
- Complete clinical workup to identify syndrome & its causes
- General supportive care incl security, stimulation, patience, nutrition
Medications in NCD
Cognitive impairment: ____
- Donepezil
- Rivastigmine
- Galantamine
cholinesterase inhibitors
NMDA receptor antagonist
____
Memantine (Namenda)
Pharmaceutical agents for agitation, aggression, hallucinations, thought disturbances, wandering = ____
Risperidone
Olanzapine
Quetiapine
Haloperidol
Pimavanserin (PD)
Consider anticholinergic effects
antipsychotics
Depression = Antidepressants
SSRIs
* Sertraline
* Paroxetine
Tricyclic Antidepressant
* Nortriptyline
- Trazodone
Anxiety = Benzodiazepines
- Diazepam
- Chlordiazepoxide
- Alprazolam
- Lorazepam
- Oxazepam
☆ Antipsychotics in Lewy Body Disease ☆
☆ Understand how Alzheimer’s meds work ☆
