Week 8: Neurological/Neurogenerative Disorders Flashcards
Aging Changes and Their Effects on the Nervous System Effects: The Brain
- Breakdown of nerves can affect the senses
- Blood flow to brain may decrease by 20%
- Slowing of though, memory and thinking is a normal part of aging
- Dementia and severe memory loss are NOT a normal part of aging.
Aging Changes and Their Effects on the Nervous System: Vertebra
The disks between the vertebra become hard and brittle, as well as part of the Vertebra may over grow
Aging Changes and Their Effects on the Nervous System: Nerves
- Peripheral Nerves may conduct impulses more slowly -> decreased sensation and often some clumsiness
- PNS response to injury is reduced.
Neurogenerative Disorders: Diagnosis
- Evaluation done when changes are noted in comparison to a prior state of cognition, especially memory or physical stability such as balance or tremors.
- Diagnostic process begins with the assessment of potentially all reversible causes for changes such as delirium, infection, vitamin deficiencies or endocrine disturbances.
Signs and Symptoms of Neurocognitive Disorders
- Decline from prior state with slow onset
- Decline in memory and learning
- Potential declines in attention, executive function, language, perceptual motor, social cognition
- Fluctuating cognition
- Recurrent hallucinations
- Movement disturbances
- Possible sleep disturbances
- No evidence of reversible causes for symptoms
Parkinson’s Disease
-In late stages, many develop NCDs, referred to as PD dementia.
Parkinson’s Disease: Diagnosis
- Diagnosis can be made with reasonable certainty considering the absence or presence of classic signs and symptoms
- Confirmed by a “challenge test” when symptoms improve dramatically after the administration of levodopa.
Characteristics of other movement disorders include
- Early falls
- Poor response to levodopa
- Symmetry of motor symptoms
- Lack of tremor
- Early autonomic dysfunction
Parkinson’s Disease: Etiology
- Deficiency of the neurotransmitter dopamine, a reduction in dopamine receptors and the accumulation of LB, especially in the basal ganglia.
- Epigenetic factors influence development
Severity of Parkinson’s Disease is associated with
Degree of neuron loss.
Parkinson’s Disease: By the time a person becomes symptomatic,
70-90% of dopamine producing cells are lost.
What are the four core signs of Parkinson’s Disease?
- Resting Tremor
- Muscular Rigidity
- Bradykinesia
- Asymmetric onset
-Muscle rigidity is another symptom
What is often the first sign of Parkinson’s Disease?
Resting Tremor
Muscle Rigidity and bradykinesia may worsen in PD, affecting the
Striated muscles in the extremities, trunk and ocular areas, including muscles of chewing, swallowing and speaking.
Is there a cure for Parkinson’s Disease?
No cure for PD, but when symptoms interfere with function, pharmacological interventions are initiated.
What medications are used to treat parkinson’s disease?
- First line medication: Levodopa
- Other drugs: Carbidopa and dopamine agonists.
When medications don’t provide relief from disabling symptoms of PD, patients may elect to have surgical intervention such as
Deep brain simulation or ablation
Nonpharmacological treatment for PD includes
Gait training and muscle strengthening
Alzheimer’s Disease: Etiology
- Familial AD, caused by a single gene mutation on one of three chromosomes: 21, 14 or 1.
- Most AD in persons >60 is likely due to a number of factors
- APOE gene type e4 is found in 40% of late onset AD
Persons with NCD d/t AD also have increased number of
B-amyloid proteins outside the neuron and accumulation of tau proteins inside the neuron.
Symptoms of Alzheimers Disease include
- Initial symptom is memory loss, specifically the ability to remember new information
- Additional S&S develop overtime
- Functional decline correlates to cognitive decline.
5 A’s To Alzheimer’s Diagnosis include
- Anomia: inability to remember names
- Apraxia: missuse of objects because of failure to identify them
- Agnosia: inability to recognize familiar objects, tastes, sounds and other sensations
- Amnesia
- Aphasia: inability to express oneself through speech
Diagnosis of NCD due to Alzheimer’s Disease requires
- a decline from previous level of functioning.
- the onset was insidious.
- there has been a gradual progression in cognitive abilities.
NCD disorders are now characterized as
Possible or probably and major or minor
Pharmacological therapy for Alzheimer’s Disease is aimed at
Slowing cognitive decline
Medications used to treat Alzheimer’s Disease include
- Cholinesterase inhibitors: donepezil, galantamine, rivastigmine
- Regulation of the activity of glutamate: memantine HCl
Neurocognitive Dementia with Levy Bodies (LB)
-Cognitive changes always precede movement disorders
Signs and Symptoms of Neurocognitive Dementia with LB
- Severe loss of thinking, especially problem solving, use of language and numerical concepts.
- Fluctuating attention and alertness
- Hallucinations which may lead to delusions and paranoia
- Disordered sleep
- Mood problems: depression, apathy, anxiety and agitation
- Autonomic S&S
Neurocognitive Dementia with LB: Etiology
- Normal healthy brains have alpha-synuclein proteins that help neurons communicate with each other at their synapse, but in LB abnormal spherical protein aggregates are found within neurons.
- Alpha-synuclein is highly expressed with these bodies, which displace other cellular structures and may contribute to cell death.
- Progression of the disease leads to significant deficits in neurotransmitter production along the cholinergic and dopaminergic pathways.
Neurocognitive Dementia with LB: Diagnosis
- According to the new DSM-5 diagnostic criteria, the person identified as one with NCD due to LB must first meet all of the initial mild or moderate criteria for other NCDs and then be classified as “possible” or “probable”.
- Based on the presentation of the core features
Pharmacological Treatment for Neurocognitive Dementia with LB
- Cholinesterase inhibitors
- Benzodiazepines
- Clonazepam
What type of medication should never be used in people with NCD due to LB?
Typical antipsychotics (i.e. Haldol) can never be used in persons with NCD due to LB due to a very high rate of irreversible side effects and possible death.
Complications of Neurocognitive Dementia with LB include
- Pressure Ulcers
- Pneumonia
- Dysphagia
- Aspiration
- Under nutrition and weight loss
- Behavioral Disturbances
Treatment for these disorders focuses on:
- relieving symptoms with medication.
- increasing functional ability.
- preventing excess disability.
- decreasing risk for injury.
Key factors in care of the gerontological population include
- appropriate use of nonpharmacological and pharmacological interventions.
- prompt treatment of reversible conditions.
- coordination between all care providers.
What are the three D’s of cognitive impairment?
- Depression
- Delirium
- Dementia (Mild and major NCDs)
Delirium is characterized by
An acute or subacute onset with symptoms over a short period of time.
Major and mild NCD: Characteristics
- Gradual onset
- Slow steady pattern of decline without alterations in consciousness.
Predisposing Factors for Neurocognitive Disorders
- Underlying cognitive impairment
- Functional impairment
- Depression
- Acute illness
- Sensory impairment
Precipitating Factors for Neurocognitive Disorders
- Medications
- Procedures
- Restraints
- Iatrogenic events
- Sleep deprivation
- Bladder catheter
- Pain
- Environmental factors
Older patients with NCDs are
3-5 times more likely to develop delirium
Delirium superimposed on NCDs can
Accelerate the trajectory of cognitive decline and is associated with high mortality
Recognition of Delirium
- Is a medical emergency and one of the most significant geriatric syndromes.
- Failure to recognize delirium, identify underlying causes and implement timely interventions contribute to negative sequelae.
Risk factors for delirium
Box 29-1
Drugs that cause or contribute to Delirium include
…
Clinical Subtypes of delirium include
- Hyperactive
- Hypoactive
- Mixed
Recognizing delirium
Box 29-4
Consequences of Delirium
- Terrifying experience for the individual and his or her family and significant others
- Associated with increased length of stay and hospital readmissions, increased services after discharge, increased morbidity, mortality, and institutionalization, independent of age, co-existing illness, or illness severity.
Assessment of Delirium
- Begins with a good history and identification of key diagnostic features.
- MMSE-2 alone is not adequate for diagnosing delirium.
- Confusion Assessment Method (CAM) (Box 29-8, Touhy & Jett).
- NEECHAM Confusion Scale.
Nonpharmacological Interventions for Delirium include
- Person-centered approach to delirium
- Hospital Elder Life Program
- Interventions to prevent delirium
Care of Individuals with Mild and Major NCD: Overriding Goals
The overriding goals in caring for older adults with dementia are to maintain stability and function, compensate for the losses associated with the disease, and create a therapeutic milieu that nurtures the personhood of the individual and maintains quality of life.
How often should assessment for neurological disorders be done?
Occurs every 6 months to 1 year after diagnosis or at any time there is a change in behavior or increase in the rate of decline.
Areas of concern for caregivers of persons with mild NCD and EOD center less on personal care and more on
Communication, behavior and relationships
Person-centered care in patients with Neurocognitive disorders
Irreversible NCDs have no cure, and although medications offer hope for improved function, the most important treatment for the disease is competent and compassionate person-centered care.
Communication in older adults with Neurocognitive disorders
- Communication with older adults experiencing NCDs requires special skills and patience.
- Even in later stages of NCD, the person may understand more than you realize and still needs opportunities for interaction and caring communication, both verbal and nonverbal.
- To effectively communicate with a person experiencing NCD, it is essential to believe the person is trying to communicate something important.
- The person with NCD cannot change his or her communication; we must change ours
Progressively Lowered Stress Threshold Model
…
Need-Driven Dementia-Compromised Behavior Model
..
Bathing of persons with dementia
Can be perceived as a personal attack by persons with dementia, who may respond by striking out.
Wandering associated with dementia
- One of the most difficult management problems encountered in the home and institutional settings.
- Defined as “a syndrome of dementia-related locomotion behavior having frequent, repetitive, temporarily disordered and/or spatially disoriented nature that is manifested in lapping, random, and/or pacing patterns, some of which is associated with eloping …”
Assessments for Wandering Associated with Dementia
- Careful assessment of physical problems that may trigger wandering, such as acute illness, exacerbations of chronic illness, fatigue, medication effects, and constipation.
- Interventions for wandering (Box 29-27, Touhy & Jett).
- Wandering behavior may also result in people with dementia going outside and getting lost.
- Recommendations to avoid individuals with dementia getting lost (Box 29-28, Touhy & Jett).
Nutrition in Older Adults with Dementia
- Older adults with dementia are particularly at risk for weight loss and inadequate nutrition.
- The Mini Nutritional Analysis is an easy tool to identify those at risk.
- One of the best strategies for managing poor intake is establishing a routine so the older person does not have to remember time and places for eating.
- Improving intake for individuals with dementia (Box 29-29, Touhy & Jett).
