Unit 6 Neurocognitive Disorders DELEREIUM, DEMENTIA, ALZHEIMERS Chapter 23

Question 1

What is Delirium

Answer 1

Acute, Suden, onset of confusion can be due to…

• Pain
• Infection
• Dehydration
• Hypoxia
• Immobilization
• Poor or inadequate nutrition
• Environment noise, lack of orienting material, movement to new area
• Sleep deprivation
• Sensory problems, especially hearing and vision
• Restraint use
  SUBSTANCE ABUSE

Cognitive Disturbance and often reversible
Common complication in hospitalized older adult
Always due to underlying cause
Important to identify cause early and treat
Risk Factors: Cognitive impairments, infection, older
age, fracture, polypharmacy

Question 2

Should a patient who is newly confused, falling, disrobing and fighting with staff be assessed for delirium?

A. Yes
B. No

Answer 2

A. Yes

Question 3

Is Delirium short term?

Answer 3

YES

Question 4

Before diagnosing a patient with delirium what should be assessed first?

Answer 4

-obtain family history of baseline of normal functioning

Question 5

What is the priority way to treat Delirium?

Answer 5

treat the underlying causes

Question 6

Is delirium a medical emergency?

A. Yes
B.No

Answer 6

A. Yes

**Delirium is a medical emergency that requires immediate attention to prevent irreversible and serious damage **

(Dixon, 2018). Delirium is associated with increased morbidity and mortality and can have lasting long-term consequences, such as permanent cognitive decline (Inouye, 2018).

In hospitalized patients, delirium is associated with longer hospital stays and increased complications

Question 7

Is delerium progressive or reversible?

Answer 7

REVERSIBLE

Question 8

S/s of Delirium

Answer 8

Cardinal Symptoms:
◦ Inability to direct, focus, sustain, and shift attention
◦ Abrupt onset
◦ Clinical features fluctuate w/ periods of lucidity(high and low moods)
◦ Disorganized thinking
◦ Poor executive functioning(poor financial management, paying bills

Question 9

Your patient has active onset hallucinations should you consider delirium?

A. Yes
B.No

Answer 9

A. Yes

Consider delirium when:
◦ Patient abruptly demonstrates a reduced clarity of environment.
◦ Impaired ability to direct, focus, sustain or shift attention
◦ Disorientation
◦ Conversation is difficult
◦ Illusions or Hallucinations

Question 10

Is safety a priority in patient with delirium?

A. Yes
B. No

Answer 10

A. Yes

Question 11

Can hallucination or illusions be present in patients with Delirium?

A. Yes
B. No

Answer 11

A. Yes

Consider delirium when:
◦ Patient abruptly demonstrates a reduced clarity of environment.
◦ Impaired ability to direct, focus, sustain or shift attention
◦ Disorientation
◦ Conversation is difficult
◦ Illusions or Hallucinations

Question 12

Interventions for Delirium

Answer 12

Physical needs
◦ Sx – increased HR, Flushing, hypervigilant
◦ Lighting – Simple environment
◦ Glasses and/or hearing aides

*Make environment simple and clear as possible.**

Eyeglasses, hearing aids, and ade- quate lighting without glare can maximize the person’s ability to interpret more accurately what is going on in the environment.

Interpersonally interacting with the patient when the patient is awake can help to reduce anxiety and misperceptions.

Question 13

Which of the following s/s is associated with delirium?

A. Diaphoresis
B. Bradycardia
C. Pupil constriction
D. Incontienece

Answer 13

A. Diaphoresis

Autonomic signs—such as tachycardia, sweating, flushed face, dilated pupils, and elevated blood pressure—are often present in delirium. Monitor and document these changes care- fully, as they may require immediate medical attention.

Question 14

Mood and behavioral changes that patients experience with delirium?

Answer 14

Mood and Behavior
◦ Dramatically change and swing
◦ Anxiety, fear, anger, euphoria

Question 15

Which of the following should you suspect is a potential cause of delirium in a patient?

A. Family history
B. Potassium 3.8
C. Sodium 145
D. Medication

Answer 15

D. Medication

TREAT THE CAUSE , DISCONTINUE MEDICATION
You should always suspect medications as a potential cause of delirium.

This is especially true when there is polypharmacy and/or use of psychoactive agents.

To recognize drug reactions or anticipate potential interactions before delirium actually occurs, it is important to assess all medications, prescriptions, and over-the- counter agents that the person is taking.

Consultation with a pharmacist is recommended, especially when there is polypharmacy.

Question 16

How would a nurse prevent delirium if the older adult has polypharmacy?

Answer 16

**To recognize drug reactions or anticipate potential interactions before delirium actually occurs, it is important to assess all medications, prescriptions, and over-the- counter agents that the person is taking. **

medication reconciliation

Question 17

What is the proper nursing communication technique with a patient with the delirium during the assessment process?

A. repeat the question , patient ability to focus may be reduced.
B. turn on all lights and alarm machines to wake the patient up.
C. Speak loudly while your back it turned against them
D. Have them write out how they feel about themselves

Answer 17

A. repeat the question , patient ability to focus may be reduced.

Question 18

Which hospital setting would a patient be presented with delirium?

A. Post operative floor
B. Intensive Care Unit
C. Medical surgical floor
D. Psychiatric mental facility

Answer 18

B. Intensive Care Unit

Question 19

What is the priority outcome for patients with Delirium

Answer 19

Outcomes
◦ Free from injury

Question 20

What is Dementia

Answer 20

Dementia – broad term used to describe progressive deterioration of cognitive functioning
and global impairment of intellect
Dementia is a umbrella term
◦ Important to rule out Depression or any medical cause
◦ Don’t assume “normal part of aging”

Question 21

Should you assume memory loss is a part of normal aging?

A. Yes
B. No

Answer 21

B. No

◦ Don’t assume “normal part of aging”

Question 22

What is Alzheimer’s Disease?

Answer 22

AD, the most common cause of dementia, is a devastating disease that not only affects the person experiencing it but also places an enormous burden on the families and caregiv- ers of those affected.

Question 23

Risk factors for Alzimers

Answer 23

Risk Factors: Genetics, Cardiovascular disease, Head injury, Traumatic Brain injury, unhealthy
diet, not socially engaged

Question 24

Which of the following hormones is patients with Alzheimers disease Deficient in ?

A. Estrogen
B. Acetycholine
C. Levothroxixne
D. Antidiuretic hormone

Answer 24

B. Acetycholine

Deficiency of acetylcholine

Question 25

What is the function of acetylcholine

Answer 25

an important neurotransmitter that plays a role in brain functions, such as memory, and body functions, such as muscle contractions to move your muscles.

Question 26

How many stages of Alzheimers is there ?

Answer 26

3

◦ Early
◦ Moderate to severe:
◦ Late:

Question 27

Early Stage Alzheimers

Answer 27

forgetfulness

• Early – Difficulty with recent memory, impaired learning, apathy and depression

The person and their loved ones notice memory lapses. The person may still be able to function independently but will experience:

• Difficulties retrieving correct words or names.
• Trouble remembering names when introduced to new people.
• Challenges in performing tasks in social or work settings.
• Forgetting material that one has just read.
• Losing or misplacing a valuable object.
• Increasing trouble with planning or organizing.

Question 28

◦ Moderate to Severe Alzheimer’s

Answer 28

Moderate to severe: Visual/spatial and language deficits, psychotic features, agitation and wandering

The person confuses words, gets frustrated or angry, or acts in unexpected ways such as refusing to bathe. Symptoms become noticeable to others and such persons may
* Forget events or their personal history
* Become moody or withdrawn, especially in socially or mentally challenging situations

• Be unable to recall their own address or telephone number or the high school/college from which they graduated.
• Become confused about where they are or what day it is
• Need for help choosing proper clothing for the season or the occasion
• Change sleep patterns, such as sleeping during the day and becoming restless at night

Be at risk of wandering and becoming lost
* Become suspiciousness and delusional or
compulsive, for example, repetitive behavior like hand wringing

Question 29

Should you use antipsychotics with elder adults?

A. Yes
B. No

Answer 29

B. No
can have Paradoxical effects

Question 30

Severe Alzheimers

Answer 30

Gait Disturbance, poor judgment, disorientation, confusion, incontinence, difficulty speaking swallowing and walking

Patients lose the ability to respond to their environment, to carry on a conversation, and, eventually, to control movement. They may still say words
or phrases, but communicating pain becomes difficult.
Personality changes may take place and individuals need extensive help with daily
activities. They may:

** Require full-time, around-the-clock assistance with daily activities and personal care**

** Lose awareness of recent experiences and of their surroundings**

• *Experience changes in physical abilities,
  including the ability to walk, sit, and eventually swallow**
• Have increasing difficulty communicating
• Become vulnerable to infections, especially pneumonia

Question 31

Assessment Terminology for Alzheimer Disease)

Answer 31

Confabulation – creation of stories/answers in place of actual memories to maintain self-esteem (unconscious
not lying) Defense Mechanism

Perseveration – persistent repetition of a word, phrase or gesture. Continues after the stimulus is stopped.

Agraphia – diminished ability to read or write
Aphasia – loss of language ability
Apraxia – loss of purposeful movement
Agnosia – Loss of sensory ability to recognize objects
Hyperorality – tendency to taste, chew and put everything in mouth
Hyper metamorphosis – urge to touch everything
Sundowning – tendency for mood to deteriorate and agitation increases in the later part of the day or at night
Assess Cognitive Functioning, memory, executive functioning, emotions

Question 32

Confabulation example

Answer 32

Confabulation is the creation of stories or answers in place of actual memories to maintain self-esteem.

-Confabulation is not lying. When people are lying, they are aware of making up an answer. Confabulation is an unconscious mechanism employed to protect the ego.

For example, here the nurse addresses a patient who has remained in a hospital bed all weekend:
Nurse: Good morning, Ms. Jones. How was your weekend? Patient: Wonderful. On Sunday I went to lunch with my
family.

Question 33

What is Perseveration

Answer 33

Perseveration is the persistent repetition of a word, phrase, or gesture that continues after the original stimulus has stopped. For example, a person may continue to repeat “hello” long after the initial greeting is over.

Question 34

What is Agraphia

Answer 34

difficulty Writing

Question 35

What is Aphasia

Answer 35

Aphasia – loss of language ability

Question 36

What is Apraxia

Answer 36

Apraxia – loss of purposeful movement

Question 37

What is Agnosia

Answer 37

Agnosia – Loss of sensory ability to recognize objects

Question 38

What is Hyperorality

Answer 38

Hyperorality – tendency to taste, chew and put everything in mouth

Question 39

What is Hyper metamorphosis

Answer 39

Hyper metamorphosis – urge to touch everything

Question 40

What is Sundowning

Answer 40

Sundowning – tendency for mood to deteriorate and agitation increases in the later part of the day or at night
Assess Cognitive Functioning, memory, executive functioning, emotions

Question 41

Interventions for patients with Alzheimers Disease

Answer 41

Person Centered Care – focuses on forming meaning relationship with the person who has
dementia and also their caregiver

Educating families about cognitive impairment – Involve families in treatment planning

Community supports
Use of distraction
Finger foods(NO COMPLICATED. FOODS)
Limit number of choices

Monitor nutrition and weight(MONIOTOR FOR WEIGHT LOSS)

Question 42

Home Care Guidelines

Answer 42

Safe Environment
◦ Falls
◦ Driving/Cooking
◦ Minimize sensory stimulation
Wandering
◦ Medical Alert Bracelet
◦ Notify police, neighborhood
◦ Complex locks on door

Useful Activities
◦ Exercise that allows exercise of large muscles
◦ When ability to read diminishes, provide children’s books

Question 43

Function of Cholinestrase

Answer 43

Cholinesterase inhibitors. Because a deficiency of neural acetylcholine has been linked to AD, some medications aim to prevent its breakdown. These drugs function by inhibiting cholinesterase from breaking down acetylcholine into its components of acetate and choline. This allows for an increase in the availability and duration of action of acetylcholine, which leads to temporary improvement of some symptoms of AD.

Question 44

Medications for Alzheimers Disease

Answer 44

Cholinesterase Inhibitors:increases available acetochyline
◦ Donepezil (Aricept)
◦ Rivastigmine (Exalon)
◦ Galantamine (Razadyne ER)

^THESE DRUGS TREAT THE SYMPTOMS OF ALZHEIMERS
There is no cure

Question 45

Use of Donepezil

Answer 45

◦ Donepezil (Aricept)
-Modestly improves cognition in mild to moderate dementia of Alzheimer’s
Donepezil is also approved for severe Alzheimer’s disease
Small but short lived improvements

Question 46

Side effects of Cholinesterase Inhibitors

Answer 46

SE –
-Nausea,
-Vomiting,
-diarrhea,
-insomnia,
-fatigue,
-muscle cramps,
-incontinence,
-bradycardia
and syncope.
-GI UPSET
Risk of Side Effects double in those over age 85

Question 47

NMDA Receptor Antagonist, effects

Answer 47

Memantine (Namenda)
Regulates glutamate activity by blocking NMDA receptors, thereby decreasing excitatory neurotoxicity
Moderate to severe Alzheimer’s disease

SE – Dizziness, agitation, headache, constipation, and confusion

Question 48

Goal for Patients with Alzheimers

Answer 48

Integrative Therapy and Evaluation

*Aromatherapy

*Calming interventions

*Overall goal is to promote the person’s optimal level of functioning and to delay further regression

*Outcome criteria – individualized, measurable and within the individual’s capabilities