Delirium, Dementia, and Depression

B. The client

A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the consent form? A. Client's partner B. The client C. The client's daughter, who is the primary caregiver D. The client's son who has a durable power of attorney

A. orthostatic hypotension

A nurse is caring for a client who has a new prescription for phenelzine for the treatment of depression. Which of the following indicates that the client has developed an adverse effect of this medication? A. orthostatic hypotension B. Hearing loss C. Gastrointestinal bleeding D. Weight loss

B. Fever

A nurse is caring for a client who has been taking sertraline for the past 2 days. Which of the following assessment findings should alert the nurse to the possibility that the client is developing serotonin syndrome? A. Bruising B. Fever C. Tinnitus D. rash

c. makes up stories when he is unable to remember actual events

A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client: a. displays compulsive and ritualistic behaviors b. reminisces about the past c. makes up stories when he is unable to remember actual events d. refuses to leave home to see a provider

onset, duration, progression, and course of symptoms

Assessment of Dementia/Alzheimer's disease: · Obtain a thorough history and be sure to differentiate between dementia and delirium § Dementia patients are at risk for Delirium when they are hospitalized § Obtain information from family members because the patient may be unaware of problems, deny their existence, or cover them up. § Obtain ____________________________: changes in memory, increasing forgetfulness, ability to perform ADLs; employment status and work history or military history; ability to clean, shop, prepare meals; changes in driving; ability to handle finances; language/communication; changes in smell § Assess functional status for complex chronic conditions (like dementia) · Assess for the stage of Dementia

Care Giver Strain Index assessment

Caregiver Strain · Being a caregiver puts them at a higher risk for stress and depression · ___________________ is a screening tool · Assists nurse in determining the degree of caregiver strain · Elder Abuse · Abandonment

· Fear/uncertainty-allow them to talk · Change in family dynamics · Change in family living situation · Financial burdens · Learning to care for family member-assist with ADLs, treatments, recognize crisis's · Learn about restrictions and may need help adjusting their own lifestyle · May cause distance between family members

Impact on the Family/Caregiver:

institutionalized care

Late-Stage Issues with Dementia · There comes a time when family cannot manage home care anymore and must seek ______________________. This decision carries dual concerns: § Finding an appropriate facility § Managing the guilt of transferring care to another · When a person's needs overwhelm home or assisted-living care, a skilled nursing facility is required. An ideal nursing facility provides for basic needs, meets overall healthy needs, and promotes quality of life in daily living. · REMEMBER: too much info can be overwhelming, so nurses should teach the older person and family what they need to know tomorrow, not next year · Family caregivers must be supported in dealing with feelings of inadequacy and guilt. ("you have done such a good job of caregiving. Look at the nursing-home staff. It takes of team of nurses working three shifts a day, seven days a week to do what you have been doing") · Reiterate that AD will continue to worsen and decline · Bringing the older person to view the facility can ease the transition. Still, it takes about 3-6 months for the older person with AD to adjust to changes in living environment and functional decline may ne inevitable and expected

distract or place your hand on theirs to calm them

Managing Behavioral Problems in the Older Adult: Tips for the Caregiver · Anxiety and agitation can sometimes be caused by bodily discomfort or pain, constipation, or hunger. Try figuring out what might be wrong. · Stay calm, as your anxiety will increase their anxiety. · Change in surroundings or routine can be disorienting for someone with dementia. Reassurance is necessary. Identify and acknowledge their feelings and let them know they are safe and you are with them. · Many people with dementia become paranoid and feel threatened by everything from a stranger to a piece of mail. If they are having delusions or hallucinations, do not try to talk them out of them, but rather _________________________________. · KEEP THEM ON A SCHEDULE: Time of day, time of meals, time of events at home can all trigger behavioral issues. For people who sundown, late afternoon can be a challenge. Some people are better in the mornings, others later in the day. Plan activities around when the person is at his/her best · Going for a walk outside or a walk around the house will get the person moving, which is both a distraction and also helps to reduce anxiety. · If an activity, such as dressing, is frustrating, help the person to finish the task, using soothing words of reassurance. Then engage him/her in a new activity where he/she will be successful, such as folding towels. · Overstimulation, too much noise, the TV, too many people can all cause agitation. Soothing music or familiar songs can sometimes help. Keep the environment as stress free as possible · Do not try to physically restrain someone who is upset unless there is an immediate safety concern. · People with sleep disturbances should be evaluated by their neurologist and/or someone with expertise in handling sleep problems. · Behavior issues are the way the person you are caring for is using to try and communicate something to you. Look behind the behavior like a detective and try to figure out what is causing it. Suggestions for Caregivers of Older Adults with Mental Health Problems · Share the responsibility for care. Do not take on more than you can handle, and involve others who can help · Meditate, listen to music, or take a walk everyday. Take care of yourself · Set priorities and work on one problem at a time. Doing too much will make you distracted, frustrated, and at loose ends. Make a list and cross tasks off · Maintain physical health. Get regular checkups, take medications, eat well, avoid alcohol and caffeine, exercise regularly · Seek love and support from family, friends, clergy, and others. Do not be afraid to seek additional help and recognize when counselling is needed to cope with decisions · Education yourself about your loved one's situation. Knowledge is power · Join a local support group. Contact local aging resource center for phone numbers · Accept yourself. Do not strive for perfection. Self-acceptance and nurturing will go a long way

Orthostatic hypotension

Pharmacological Treatments for Depression - Monoamine Oxidase inhibitors (MAOIs) are sometimes used in older adults with dementia and depression § ____________________ is common and peaks about 4-5 weeks after starting therapy § Side effects: drowsiness, dizziness, increased sun sensitivity, blurred vision Hypertensive crisis can occur if taking with other drugs that risk BP (anticholinergics, stimulants) and tyramine foods (red win, cheese, beer, bologna, pepperoni, liver, raisins, banana).These restrictions also apply during use and for 14 days following discontinuation of MAOIs

low in the terminal stage of dementia

Transfer to an Acute-Care site Treatment of infections § Infections are inevitable in advanced dementia due to chances in immune function, incontinence, decreased mobility, and aspiration. § Atypical presentations of pneumonia/infection in older adult (no fever, leukocytosis, cough): altered level of function, falls, increased confusion, new incontinence Infections are treated with antibiotics, but its effectiveness is _________________________

A. actions to reduce stress B. identification of a social support system C. referral to available community resources E. expected physiological changes of the disease

a home health nurse is reinforcing coping strategies with the family caregiver of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? (select all that apply) A. actions to reduce stress B. identification of a social support system C. referral to available community resources D. instruction on client medication administration E. expected physiological changes of the disease

Alzheimer's Disease

· Risk factors for _____________________: § Age older than 65 § Female gender § Genetics: (APOE gene, ABCA4 gene, APP gene, PSEN1 gene, PRESN 2 gene) § family history § Chemical imbalances § Environmental agents: herpes zoster virus, herpes simplex, toxic metals (zinc copper) § Immunologic changes § Stress § African American, Hispanic race § Traumatic brain injury, repeated head trauma § Diabetes mellitus § Frailty § High cholesterol § Smoking, physical inactivity § Obesity § Low vitamin D § Depression § Down syndrome § Most cases result from interactions between genetic and environmental factors. Advanced age being the single greatest factor. One or both patents with hx is second greatest factor. (maternal factor). § Higher education is correlated with later onset of dementia. § More varied activities and greater social networks also correlate with later onset of dementia. § Medical risks include: head trauma, DM, frailty, high cholesterol levels, cigarette smoking, lack of physical activity, obesity, low Vitamin D levels, high levels of stress and clinical depression.

Stage 3 Late-Severe

· _________________________: in this stage of dementia and AD, the older adult needs around-the-clock care (incontinence of bowel/bladder), may need help with feeding, and is vulnerable to infections (pneumonia, decubitus ulcers) § Completely incapacitated; bedridden § Totally dependent in ADLs § Loss of mobility and verbal skills; can't communicate with others § Incontinence § Lost awareness of environment § Progressing difficulties with mobility (walking, sitting, swallowing); eventually loses ability to move (stupor, coma) § Agnosia (loss of facial recognition) § Death is usually related to choking or infection (very vulnerable to pneumonia)

D. Talk the client through asks one step at a time

A charge nurse in a long-term facility is planning care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the care plan? A. Rotate assignment of daily caregivers B. Provide an activity schedule that changes everyday C. Limit time to perform activities D. Talk the client through asks one step at a time

B. Your mother died over 20 years ago

A client with early dementia asks the nurse to find her mother who is deceased. What is the nurse's most appropriate response. A. We can call her in a little while if you want B. Your mother died over 20 years ago C. What did your mother look like D. I'll ask your father to find her when she visits

D. Forgetfulness gradually progressing to disorientation

A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect? A. Decreased auditory and visual acuity B. Decreased display of emotions C. Personality trains that are opposite of original traits D. Forgetfulness gradually progressing to disorientation

D. Respite care

A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make? A. Hospice B. Restorative care C. Mental health care D. Respite care

C. Provide consistent daily routine

A nurse in a long-term care facility is caring for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care? A. Post a written schedule of daily activities B. Use an overhead loudspeaker to announce events C. Provide consistent daily routine D. Allow the client to choose free-time activities

A. Take the client to the bathroom every 2 hrs

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? A. Take the client to the bathroom every 2 hrs B. Remind the client to tell the nurse when he has to urinary C. Use adult diapers to prevent frequent clothing changes D. Request a prescription for an indwelling catheter

C. -Ask the partner to talk about his difficulties in caring for the client

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. -Recommend that the partner place the client in a long term care facility B. -Suggest that the partner see a counselor to help him cope with his exhaustion C. -Ask the partner to talk about his difficulties in caring for the client D. -Tell the partner to call a family meeting to get help

B. "It was good. The Queen of England visited me there."

A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation? A. This morning, this morning, this morning... B. "It was good. The Queen of England visited me there." C. I just don't remember what I did this morning D. Snip, snap. Take a nap

B. Place the client in a room close to the nurse's station

A nurse is caring for a client who has Alzheimer's disease and fall frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client B. Place the client in a room close to the nurse's station C. Encourage the client to ask for assistance D. Remind the client to walk with someone for support

A. Exposure to metal waste products D. Previous head injury E. History of herpes infection

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (SATA) A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

C. Place a seat alarm on the client's chair

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first? A. Apply a vest restrain on the client B. Place the client in a bed with two side rails raised C. Place a seat alarm on the client's chair D. Administer lorazepam

A. Ability to perform calculations B. Recall ability C. Long-term memory D. level of orientation

A nurse is caring for a client who has dementia. When performing a mental status examination the nurse should include which of the following data? A. Ability to perform calculations B. Recall ability C. Long-term memory D. level of orientation E. Coping skills

A. Mydriasis B. Dizziness C. Decreased libido

A nurse is caring for a client who has depression and a new prescription for venlafaxine. For which of the following adverse effects should the nurse monitor this client? (select all that apply) A. Mydriasis B. Dizziness C. Decreased libido D. Alopecia E. Hypotension

a. Assist the client to the correct room

A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take? a. Assist the client to the correct room b. Place the client in restraints. c. Reorient the client to time and place. d. Move the client to a room at the end of the hall.

C. Keep familiar personal items at the bedside

A nurse is caring for a confused client who has Alzheimer's disease. Which of the following actions should the nurse take? A. Turn the TV on at all times B. Hang abstract pictures on the walls C. Keep familiar personal items at the bedside D. Encourage bright glaring light in the room

b. a client attempts to climb out of bed and repeatedly states she must go home

A nurse is caring for a group of older adult clients. Which of the following manifestations indicates the client is experiencing delirium? a. a client wants to know the current time while there is a clock on the wall b. a client attempts to climb out of bed and repeatedly states she must go home c. a client requests extra blankets when the thermostat in the room is 78 d. a client refuses to get out of bed and has no motivation to attend daily hygiene

C. Tell me what you like to cook for dinner

A nurse is caring with a client who has dementia due to Alzheimer's disease and was admitted to a long term care facility following the death of their partner of 40 years. The client states, "I want to go home; my husband is waiting for me to cook dinner." Which of the following responses by the nurse is appropriate? A. This is where you live now B. This is a safer place for you to live C. Tell me what you like to cook for dinner D. Your family said there is no one to care for you at home

C. The partner has lost 20 pounds in the last 2 months

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which observation indications to the nurse that the partner is experiencing caregiver role strain? A. The partner has placed locks at the top of the doors leading outside B. The partner has hired a house cleaner C. The partner has lost 20 pounds in the last 2 months D. The partner redirects the client when they are frustrated

A. Remove floor rugs C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A nurse is making a home visit to a client who has Alzheimer's disease. The client's partner states that the client is often disoriented to time and place, and is unsteady, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (SATA) A. Remove floor rugs B. Have door locks that can be easily opened C. Provide increased lighting in stairwells D. Install handrails in the bathroom E. Place the mattress on the floor

A. Grooming B. Long-term memory D. Affect

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (SATA) A. Grooming B. Long-term memory C. Support systems D. Affect E. Prescence of pain

C. -limit the client's choices for daily activities

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care? A. -provide a cognitively stimulating environment B. -rotate staff to prevent caregiver role strain C. -limit the client's choices for daily activities D. -use confrontation to manage negative behavior.

A. "You may have a decreased desire for intimacy while taking this medication."

A nurse is providing discharge teaching to a client who has a new prescription for fluoxetine for posttraumatic stress disorder. Which of the following statements should the nurse include in the teaching? A. "You may have a decreased desire for intimacy while taking this medication." B. "You should take this medication at bedtime to help promote sleep." C. "You will have fewer urinary adverse effects if you urinate just before taking this medication." D. "You'll need to wear sunglasses when outdoors due to the light sensitivity caused by this medication."

C. Change positions slowly to minimize dizziness. E. Chew sugarless gum to prevent dry mouth.

A nurse is providing teaching to a client who has a new prescription for amitriptyline for treatment of depression. Which of the following should the nurse include in the teaching? (select all that apply.) A. expect therapeutic effects in 24 to 48 hr. B. Discontinue the medication after a week of improved mood. C. Change positions slowly to minimize dizziness. D. Decrease dietary fiber intake to control diarrhea. E. Chew sugarless gum to prevent dry mouth.

C. This medication should help my husband's daily function

A nurse is providing teaching to the partner of a client who has Alzheimer's disease and has a new prescription for donepezil. which of the following statements by the partner indicates the teaching if effective? A. This medication should increase my husband's appetite B. This medication should help my husband get better C. This medication should help my husband's daily function D. This medication should increase my husband's energy level

B. Inability to perform common tasks C. Difficulty with talking or reading

A nurse is teaching a group of newly licensed nurses about the progressive nature of Alzheimer's disease. Which of the following should the nurse include in the teaching as manifestation seen in the moderate stage of Alzheimer's disease? Select all that apply. A. Inability to find commonly used items B. Inability to perform common tasks C. Difficulty with talking or reading D. Difficulty remembering how to swallow E. Inability to recognize family members

A. Syncope episodes may occur

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching? A. Syncope episodes may occur B. This medication may cause tachycardia C. You should administer the mediation each morning D. You will need to monitor for constipation

C. -The signs of dementia are progressive and irreversible

A nurse is teaching the family of an older adult client who has a new diagnosis of dementia. Which of the following statements should the nurse include in the teaching? A. -Dementia is characterized by a sudden onset of confusion B. -An altered level of consciousness is associated with dementia C. -The signs of dementia are progressive and irreversible D. -Dementia can be triggered by a high fever or dehydration

D. Reorient the client to self and current events

A nurse working in a long-term care facility is planning care for a client who has moderate Alzheimer's. Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation B. Thicken all liquids C. Provide protective undergarments D. Reorient the client to self and current events

legal documents are in order.

Assessment of Caregiver Preparedness 1. Make sure ___________________ 2. Give yourself credit for doing the best you can in one of the toughest jobs there is! · Proactive education-don't wait until the last minute. · Involve them in care (suctioning) · Want to provide family with § Education concerning disease, treatments, proper lifting § Resources in the community that could help (Day Care) § Equipment to facilitate the care process

sundowning

Assessment of Dementia/Alzheimer's disease: § Changes in Behavior and Personality: · Aggressiveness, especially verbal and physical abusive tendencies · Rapid mood swings · Increased confusion at night or when light is not adequate (__________________________) or in excessively fatigued patients · Patients may wander or become lost; or rummage through other's rooms and stuff · They may experience paranoia, delusions, hallucinations, or depression § Changes in Self-Management · Decreased interest in personal appearance · Selection of clothing that is inappropriate for the weather or event · Loss of bowel and bladder control · Decreased appetite or ability to eat (often they forget how to chew or swallow in late stages) § Psychosocial Assessment: · In early stages, patients often know they are having memory or cognitive changes and can attempt to hide them. They may begin grieving due to anticipated loss, experiencing denial, anger, bargaining, and depression at varying times. · The family may request genetic testing upon their family member's diagnosis of AD · Traumatic relocation syndrome can occur as the disease progresses when the patient is admitted to the hospital · Sexual disinhibition is challenging for family and nursing staff. Patients can show sexually inappropriate behaviors (masturbating publicly, attempting sexual acts on staff/patients, disrobing or exposing the genital area, or making sexual comments to staff/patients · As AD progresses and aphasia increases, emotions are often displayed as nonverbal behaviors (hitting, yelling, agitation) § Laboratory Assessment: · No labs confirm diagnosis of Alzheimer's disease · Diagnosis is made on basis of brain tissue examination at autopsy that confirms plaques and tangles · Genetic testing for APOE-4 can help · CT, PET scan, EEG or MRI to rule out treatable causes Lumbar puncture may be performed to detect beta protein precursor (sBPP), which supports diagnosis of AD

orientation, registration, attention and calculation, recall, speech-language

Assessment of Dementia/Alzheimer's disease: § Mini-Mental State Examination (MMSE) can be used to determine the onset and severity of cognitive impairment, and assesses 5 major areas: __________________________________________________________ . The lower the score, the greater the severity of dementia · It is not unusual for patients with AD to score 5 out of 30 or below § "Set Test" is used for patients who cannot read. The patient is asked to name 10 items in each of 4 sets: fruits, animals, colors, and towns. Patients who score above 25 do not have dementia The Short Blessed Test or Clock Drawing Test can also be used

· Apraxia: inability to use works or objects correctly · Aphasia: inability to speak or understand · Anomia: inability to find words · Agnosia: loss of sensory comprehension

Assessment of Dementia/Alzheimer's disease: · Changes in Cognition § One of the first symptoms of Alzheimer's disease is short-term memory impairment. · Cognition is the complex integration of mental processes and intellectual function for the purposes of reasoning, learning, and memory. § Assess the patient for deficits in: · Attention and concentration: decreased ability to concentrate and decreased attention span · Judgement and memory: inability to make decisions · Communication and language · Speed of information processing § Alterations in communication: - - - -

Alzheimer's Disease

Comparing Alzheimer's disease with Vascular Dementia · _________________: § Causes: genetic, environmental § Pathophysiology: chronic, terminal disease characterized by neuritic plaques, neurofibrillary tangles, and vascular degeneration § Course of dementia: steady, gradual decline of function, mobility, and cognition from mild-severe stages; patients usually die of complications of mobility § Risk factors: female, age over 65, down syndrome, TBI Management:safety measure to prevent falls/wandering/injury, cholinesterase inhibitors, behavior management, ADL and mobility

Vascular Dementia

Comparing Alzheimer's disease with Vascular Dementia · _____________________ § Causes: strokes/vascular disorders that impair blood flow to the brain § Pathophysiology: impaired blood flow to the brain, ischemia/necrosis of neurons § Course of dementia: stepwise progression of dementia symptoms that get worse after each vascular event (stroke, TIA); symptoms may improve as collateral circulation and neurons develops § Risk factors: male, age over 65, diabetes mellitus, hypercholesterolemia, MI, atherosclerosis, HTN, smoking, obesity § Management: management of risk factors (antidiabetic drugs, antihypertensives, low-fat diet, smoking cessations, weight loss); safety measures to prevent injury/fall; behavior management

prolonged hospitalization, functional decline, and increased use of chemical and physical restraints.

Delirium: · Delirium is associated with poor outcomes such as ___________________________________ · Delirium increases the risk of nursing home admission. · Individuals at high risk for delirium should be assessed daily using a standardized tool to facilitate prompt identification and management. · !!!!!!!!!! Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple co-morbidities, dehydration, psychotropic medication use (benzos), alcoholism, vision impairment and hip fractures.

old age, family history, carrying the APEO-e4 gene

Dementia: · Risk Factors for Dementia: _____________________ · On average, an older person with dementia/AD lives about 4-8 years but can live up to 20 years · The standard workup for diagnosing dementia includes a physical exam, formal/informal neuropsychological tests, labs (b12 levels, thyroid function, CBC, CMB), and imaging studies (CT, MRI) to rule out other causes (hematoma, brain tumors)

§ Seek support from other caregivers. You are not alone! § Take care of your own health so that you can be strong enough to take care of your loved one. § Accept offers of help and suggest specific things people can do to help you. § Learn how to communicate effectively with doctors. § Caregiving is hard work so take respite breaks often. § Watch out for signs of depression and don't delay getting professional help when you need it. § Be open to new technologies that can help you care for your loved one. § Organize medical information so it's up to date and easy to find. § Make sure legal documents are in order. § Give yourself credit for doing the best you can in one of the toughest jobs there is!

Family Caregivers Support · Resources for Family Caregivers · AARP · Agency on aging · www.Thefamilycaregiver.org · www.caregiver.va.gov · Mayoclinic.com · 10 Tips for Family Caregivers:

temporary and not permanent placement

Home Care Management of Dementia · The patient and family may begin to withdrawal as Alzheimer's disease progresses. Encourage them to maintain their own social contacts and leisure activities · The patient can be placed in a Respite Facility for the weekend or several weeks to give the family a chance to rest from care demands § Remind them that this is ________________ · Use an adult day care center

1. the nerve cells or neurons, which relay signals like thoughts and feelings, and the supporting cells. There are 100 billion neurons in the brain. Messages are passed within cells by tiny electrical impulses and between cells by chemical signals. 2. There is roughly one supporting cell for every neuron in the brain. These cells surround and provide support to neurons, supply nutrients and oxygen, regulate communication between neurons and act as the brain's immune system.

How the Brain Works Inside The Brain · The brain is the most complex organ. It contains many specialized cells. However, it is still not clear how these cells are linked together to perform complicated actions and why problems in cells cause changes in behavior. The cerebral cortex makes up the bulk of the brain and is the location of complex thoughts and functions. · There are two main types of brain cells: 1 2

Self-Concept

Influences of Cognitive Function · Declining cognitive function in older adults represents a huge societal and personal problem. · Older adults cognitive function is influenced by: lifestyle choices, personality factors, education, travel, socioeconomic factors, satisfaction with life, engagement in cognitively stimulating and physically demanding activity Personality and Self-Concept · Erik Erikson described the task of old age as balancing the search for integrity and wholeness, thus avoiding a sense of despair; he believed accomplishment of this ask (achieved through life-review activities) would result in wisdom · Havighurst defined tasks of later life as: § Adjusting to decreased physical strength and health § Adjusting to retirement and reduced income § Adjusting to death of a spouse § Establishing an explicit association with one's group § Adapting to social roles in a flexible way § Establishing satisfactory physical living arrangements · Older adults may express excess cautiousness due to differences in life experiences and different aging expectations; as a result, they may be hesitant to make decisions in areas where the feel less comfortable and the outcome is uncertain · _________________________________ is a component of personality that can be viewed as an attitude toward the self; it is usually developed during one's life and depends on how a person is treated by others, the successes/failures of experiences, and how the person incorporates these events into their existence. § An older person's self-concept can be eroded or enhanced over time due to circumstances and life experiences § Those who are less happy with themselves can take steps (counseling, self-help groups) to improve self-concept and change their life.

Life satisfaction

Life Satisfaction and Life Events · ___________________ is an attitude toward one's own life; it is a reflection of feelings about the past, present, and future § Age-related declines in a positive affect may be countered by increases in the sense of satisfaction with life accomplishments · Life satisfaction usually does not decrease as one ages, thus, significant changes in mood, cognitive ability, and personality should never be dismissed as normal aging, but always aggressively assesses and referred for treatment

never say "no" but offer options, provide a calm environment with music/change of scenery, avoid stress, give meaningful activities, gives rest breaks, try a drug "holiday" or discontinue, ensure caregiver/environment continuity

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · An individualized assessment should be conducted to develop specific interventions to prevent excess disability, create a therapeutic environment, actualize functional potential, and promote dignity · If known triggers result in problem behaviors, the caregiver should remove those stimuli § Problem: recent injury (fall), discomfort, pain (arthritis), physical complications (UTI), uncomfortable environment (too hot) · Treatment: individualized care, analgesic medication, adequate hydration and hygiene, infections treated with antibiotics, adjust environment § Problem: Frustrating interaction, chaotic environment, overly complex task request, nothing to occupy time, patterns (daytime fatigue) after a certain drug admin, events (changes in caregiving environment · Treatment: ______________________________________ § Problem: Dementia, mood disorders, delusions/hallucinations, functional impairment, anxiety, dependence in ADL, inability to start meaningful activities, spatial disorientation · Treatment: cholinesterase inhibitors, correct amount of assistance, non-pharm approaches, personalize living space with family pictures and items

Limit choices

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · Bowel And Bladder Continence can be maintained by using a bowel/bladder program: taking the patient to the bathroom every 2 hours. Encourage adequate fluids. · Promoting Communication With The Patient With Alzheimer's Disease § Ask simple, direct questions that require only "yes or no" § Provide verbal and nonverbal ways to communicate with the patient § Provide instructions with pictures in a place that the patient will see if they can read them § Use simple, short sentences and one-step instructions § Use gestures to help the patient understand what is being said § Validate the patient's feelings as needed § __________________________; too many choices cause frustration and increase confusion § Never assume that the patient is totally confused and cannot understand what is being communicated. § Try to anticipate the patient's needs and interpret nonverbal communication

validation therapy

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · Orient the patient. Keep communication boards for scheduled activities to promote orientation. Clocks and calendars can help maintain frequent orientation; orientation is appropriate in early stages of Alzheimer's disease. § Frequent orientation to the environment: remind them who they are, what day/time it is, where they are, who you are § Offer snacks/finger foods to the client if they won't sit for a long time § Sometimes, orientation does not work and causes agitation, thus _________________________________ is often used in moderate-severe Alzheimer's disease. This therapy encompasses recognizing and acknowledging the patient's feelings and concerns. · EXAMPLE: if the patient is looking for their mother, encourage them to talk about their mother (what she looks like, what she might be wearing). This isn't arguing with the patient but it also doesn't reinforce the patient's belief that the Mother is still living

Cognitive stimulation and memory training

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · Patients with memory problems benefit from a structures and consistent environment. · Approaches to managing the patient with Alzheimer's disease: § Cognitive stimulation and memory training, Structuring the environment, Orientation and Validation Therapy, Promoting self-management, Promoting Bowel and Bladder continence, Promoting Communication · Provide verbal prompts one at a time to decrease the chances of confusing the older adult. Even when verbal language is lost, nonverbal communication by way of tone of voice, smiling, and body language can eb comforting. Avoid pressure to perform and allow the person with dementia to continue patterns that gives a sense of security · ___________________________ reinforce or promote desirable cognitive function and facilitate memory § As the disease progresses, the patient may not recognize family members, so the family should be encouraged to provide pictures of family members and close friends that are labeled. § Encourage the family to use reminiscence therapy (take about pleasant experiences from the past), especially why assisting with ADLs or giving treatments. Refer to a personal item in the room and begin to talk about its meaning in the present and in the past. § Maintain a sleeping schedule and monitor for irregular sleep patterns. Massage therapy and essential oils (lavender, bergamot) can be used to promote relaxation § Provide them with varied environmental stimulations (walks, music, crafts) § Make lists or practice rehearsing for memory training. Stimulate memory by repeating the client's last statement

kept in the same place

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · Structure the environment. Family members should be taught to keep environmental distractions and noise to minimum. (high noise level can cause disturbed sleep, decreased nutritional intake, changes in BP/HR, and increased stress/anxiety) § The room should not have images/pictures on walls that can be confused as people/animals that could harm the patient. (abstract paintings can look like explosions). § The room should have adequate, nonglare lighting and no shadows § Objects like furniture, a hairbrush, or eyeglasses should be _______________________________. § Establish a daily routine and keep it consistent. Explain changes in routine before they occur, repeating the explanation immediately before the changes take place § Fatigue, non-routine activities, alcohol, and highly stimulating environments should be avoided because they increase functional impairment § It is not uncommon for the patient to talk to their image in the mirror, but this behavior can be allowed as long as it is not harmful. If it becomes harmful, covering the mirror may be necessary.

redirection

Management of Alzheimer's disease: Behavioral Management in a Structured Environment · Use ____________________________ by attracting the patient's attention to promote communication. If they cannot follow directions, show the what needs to be done · Interventions for physical impairments should be targeted at maintaining the highest level of functional capacity for as long as possible and restoring capacity that may be remediable § Prevent excess disability. To prevent immobility, provide assisted ambulation versus allowing the person to remain on bed rest. Encourage safe movement to the max degree possible to avoid immobility/dependency § Treat other conditions that lead to physical decline. If pain interferes with walking, give pain meds § Identify and respond rapidly to acute changes in function. Be alter to symptoms of infection § Adapt care to accommodate neuromotor changes secondary to the progression of dementia. Compensate for changes in muscle tone and reflexes that affect posture, balance, range of motion, and ability to cooperate with care § Establish a preventative program to assess mobility, prevent falls, promote proper positioning, and implement environment adaptations § Determine the best time for ADLs to prevent potential problems § Maintaining continence: prompted voiding plan every 2 hours § To assist with dressing, use garments that are easy to put on, lay the clothes out in order to be put on, provide verbal input, repeat if needed.

Donepezil

Management of Dementia · Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine): drugs approved for treating Alzheimer's disease symptoms, and work by improving cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine -_________________ can be used for dementia and Parkinson's disease dementia § Dose: 5-10mg daily PM § Precautions: withdrawal can cause cognitive decline, caution in cardiac conduction defects, seizures, NSAID use, and asthma § Side Effects: GI upset, syncope, bradycardia, seizures, urinary obstruction, AV block § Donepezil (Aricept) is also approved for both mild-moderate and moderate to severe dementia.

Galantamine

Management of Dementia · Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine): drugs approved for treating Alzheimer's disease symptoms, and work by improving cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine ____________________: § Dose: 4-12 mg BID (24mg max daily) § Precautions: take with food to avoid GI upset, titrate at 4 week intervals · Cautions with NSAID use, seizures disorder, impaired liver function, asthma, CPOD, cardiac conduction defects § Side Effects: GI upset, arrythmias, GI bleed, urinary obstruction, somnolence, tremor, ABD pain, rhinitis

Rivastigmine

Management of Dementia · Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine): drugs approved for treating Alzheimer's disease symptoms, and work by improving cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine __________________________: § Dose: 1.5-6mg BID (max 12mg daily) § Precautions: take with food to avoid GI upset, titrate at 4 week intervals § Cautions in asthma, CPOD, cardiac conduction defects, GI bleeding, seizures disorders, NSAID use § Side Effects: GI upset, seizures, urinary obstruction, hypotension, syncope, respiratory depression, paranoias, vomiting

GI disturbances

Management of Dementia · Cholinesterase inhibitors (Donepezil, rivastigmine, galantamine): drugs approved for treating Alzheimer's disease symptoms, and work by improving cholinergic neurotransmission in the brain by delaying the destruction of acetylcholine § 3 are approved for treatment of mild-moderate dementia: donepezil (Aricept), rivastigmine (Exelon), & galantamine (Razadyne) § WE WANT TO START THEM EARLY § Side effects: _________________________ § Teach the family to monitor the patient's HR and report dizziness or falls because these drugs can cause bradycardia § Use caution in patients with heart disease

Memantine

Management of Dementia · N-methyl-D-aspartate (NMDA) antagonist (___________________): this drug blocks excess amounts of glutamate that can damage nerve cells -___________________: can be used to treat moderate-severe AD by blocking abnormal glutamate action. It is the ONLY drug that can be used in addition to cholinesterase inhibitor use; usually added to slow progression of AD § Dose: 5, 10mg daily; increased 5mg every week to max of 20 mg daily § Precautions: reduce dose in renal impairment and use caution in seizure disorder § Side Effects: dizziness, headache, hypertension, constipation, cough, pain, fatigue

Tricyclic antidepressants

Management of Dementia · Selective Serotonin Inhibitors can be used for Alzheimer's disease with depression. --Paroxetine, sertraline · ______________________ (amitriptyline) should NOT be used due to their anticholinergic effects (confusion, urine retention, constipation) · Psychotropic drugs (antipsychotics, neuroleptic drugs) should be reserved for Alzheimer's disease patients with mental/behavioral problems (hallucinations, delusions) § These are chemical restraints: they decrease mobility and self-care abilities

Ginko Biloba

Management of Dementia: Complementary and Alternative Therapy · Free radicals are produced when the body breaks down food. Negative charged particles are the result of oxidation. Free radicals damage cells. · Antioxidants can stop destruction by being oxidized themselves. § Vitamin E is an antioxidant, may help prevent or delay the development of Alzheimer's/dementia. · _________________ (another antioxidant) is used for treatment of memory disorders. § May improve blood flow to the brain. § SE: bleeding, nausea, anxiety, GI disturbance, and headache. § If taken before surgery, it can cause excess blood loss · NSAIDS may lower the rate of AD.

Depression

Medications That Can Cause Symptoms of ____________________: · Analgesics: opioids (codeine, morphine), NSAIDs (ibuprofen, naproxen, indomethacin) · Antihypertensives/cardiac: clonidine, methyldopa, propranolol, reserpine, thiazide diuretics, digitalis § Beta blockers are known to cause depression · Antipsychotics: chlorpromazine, fluphenazine, haloperidol, thioridazine, thiothixene · Anxiolytics: chlordiazepoxide, diazepam, lorazepam, oxazepam · Chemo: L-asparaginase, cisplatin, tamoxifen, vincristine · Sedative-hypnotics: ethchlorvynol, flurazepam, pentobarbital, phenobarbital, secobarbital, temazepam, triazolam · Antiulcer drugs: cimetidine, ranitidine, hydrochloride · Corticosteroids: dexamethasone, prednisone · Alcohol: can make them feel more depressed · Cholesterol lowering agents (statins): simvastatin, lovastatin · PPIs and H2 blockers

stop reproducing shortly after birth

Neurons · Neurons _____________. · Because of this, some parts of the brain have more neurons at birth than later in life because neurons die but are not replaced. · While neurons do not reproduce, research has shown that new connections between neurons form throughout life.

Depression

Non-Pharm Treatment of ________________________: · Support groups that provide new coping skills and social support · Talk therapies to focus on life successes/strengths (helps them think positively) · Improving social relationships with others to improve hope for the future. · Talk therapies, light therapy, mind/body approaches, and alternative therapies (acupuncture) · Frequent visits from family or facetiming friends/family · Religious support either in person or over web services · Participation in hobbies they enjoy (keeps mind active) · Puzzles, crossword, knitting, sewing (making pillowcases, hats, scarves, or blankets for other patients or friends) · Exercise = increased endorphin production · Being outside, getting sunlight for 20 minutes/day (Vitamin D) · Pet and animal therapy with pets that don't have a lot of maintenance can help older adults feel purposeful (older pets, cats, are great for older adults) · Studies show that older adults who socialize with others are at decreased risk for depression(day care with both young and old people)

Nervous System

Normal Changes of Aging in the ________________ · The brain decreases in size and weight with aging · Neuron death occurs with aging · Nerve cells begin to transmit signals more slowly · Waste products can accumulate in the brain · Vessels in the CNS can be affected by atherosclerosis (risk for clots/stroke) · Decreased arterial perfusion to the brain can result in aging changes in cognition · Sleep disturbance/insomnia, loss of REM sleep, daytime fatigue, instability · Decreases in short-term memory and benign senescence · Depression and mood disorders are more common with aging · Level of neurotransmitters decreases, as well as the number of receptors · Glucocorticoids increase with aging (body is at risk for chronic stress, and risk for immunosuppression, HTN, hyperglycemia, bad wound repair, osteoporosis, metabolic disturbance, glaucoma, cataracts · Cells of the spinal cord decrease in number and narrowing of vertebral bodies puts pressure on the spinal cord · Peripheral nerves decline (due to wear and tear) · Bilateral loss of vibratory sense in the feet is normal but SHOUT NOT advance above the knees · Increased pain threshold, decreased sensations to light touch, pain, and joint position · Increase in reaction time but slowed responses and movements · Impaired coordination · Increased risk of physiologic tremor · Achilles reflex may be absent but quadriceps reflex should remain present · Cranial Nerve 1 (olfactory) is susceptible to decreased sensation. Changes in smell and taste can affect appetite · Slower response to decrease in BP that occurs with position change (risk for orthostatic hypotension) · Thermoregulation is affected (increased risk for hyper/hypothermia)

slower learning rate and greater need for repetition of information

Normal Changes of Cognitive Function in Aging · Normally an older person's mental health and cognition remain relatively stable, but for those that do change, usually the change is not severe enough to cause significant impairments in daily life/social ability § Most sudden changes and severe loss of cognitive function are due to physical/mental illness like stroke, serious depression, Alzheimer's disease · Normal age-related cognitive changes: § Information-processing speed declines with age, resulting in a ____________________________. § The ability to divide attention between two tasks show decline § The ability to switch attention rapidly from one auditory input to another is slowed by age-related decline (visual input switching I not usually changed) § Ability to maintain sustained attention or perform vigilance tasks appears to decline with age § Ability to filter out irrelevant information appears to decline with age § Short-term memory shows substantial changes with age, while long-term memory remains more stable § Overall prevalence of mental health problems is less than in other age groups and general life satisfaction is as good or better than other age groups § Most aspects of language are well preserved, such as use of language sounds and meaningful combinations of words. Vocabulary improves with age,. BUT word finding, naming ability, and rapid word-list generation decline with age § Visual-spatial task ability (drawing and construction) declines § Abstraction and mental flexibility show some age decline § Accumulation of practice experience (wisdom and creativity) continue until the end of life

forget what a key is or how to use it

Normal Changes of Cognitive Function in Aging · Normally, healthy older persons who forget where they put the keys can be assured there is no significant memory problem. But if they ____________________, they should be referred for evaluation · Healthy older people maintain stable personalities and psychological adaptation throughout life. Personality stability across the second half of life may be stronger than in the first half (it is still evolving during youth/middle age) · Education, mental health, general health, and activity influence cognitive ability in later life § Many older adults have a positive outlook and seek activities that maintain well-being § Many older adults take classes, participate in elder hostels, exercise, study new subjects, travel, and maintain healthy interpersonal/sexual relationships

number of neurons

Normal Neurologic Changes in Aging · Decreased ___________________ with accumulation of senile plaques and neurofibrillary tangles. · Decrease in brain size & weight with more prominent sulci. · Decreased blood flow to the brain. · Decreases in short-term memory and increased incidence of benign senescence of aging. (losing the yeti lid because you don't remember where you put it) · Depression and mood disorders become more common with aging. · Insomnia and other sleep disturbances increase including loss of REM sleep that may result in daytime fatigue and instability. · Increased pain threshold. · Increased reaction time and slowed responses and movements. · Impaired coordination. · Increased incidence of physiologic tremor (benign senile tremors). · Decreased vibratory sensation in lower extremities. · Decreased sensation to light touch, pain, joint position. Some deep tendon reflexes absent in older people

Geriatric Depression Scale (GDS)

Nursing Assessment of Depression · The ________________________ is a screening instrument used in many clinical settings to assess depression in older adults. It is a 30 item (long version) or 15 item (short version) with "yes/no" questions. It successfully distinguishes between non-/depressed older persons. § Older adults with a score above 10 should be referred for further assessment. · The Cornell Depression Scale (CDS) can be used to screen for depression in older adults with severe cognitive impairments (MMSE below 15). It relies on observations of behaviors and functional measures. § Older adults who score 12 or more on the CDS should be referred for further evaluation

Depression

Nursing Assessment of _________________________ · Symptoms of depression can be vague and unique to the individual, nurses should use various methods and multiple observations. · Look for subtle cues. · Careful and systematic assessment can lead to definitive dx and early treatment. · Symptoms of _________________________: § Emotional: sadness, diminished ability to experience joy, ability to concentrate, recurrent thoughts of death, excessive guilt over things that happened in the past § Physical: body aches, headaches, pain, fatigue, changes in sleep habits, weight gain/loss · Different Signs of _________________________ in the Older Adult: multiple somatic/physical complaints and reports of persistent, chronic pain, sleep disorders, appetite changes, guilt, inability to concentrate, suicidal thoughts; all must persist for at least two weeks. § (they won't consider depression, and only complain of physical symptoms) § Obsessions/compulsions are other symptoms of severe depression § Delusions (false, fixed idiosyncratic ideas) can be experienced by both those with depression or dementia · Delusions of persecution can occur in those with cognitive impairments · Visual and tactile hallucinations are common with delirium · Risk factors for _________________________: Female gender (but men are less likely to admit depression), low self-esteem, pessimism, easily overwhelmed by stress, serious losses, difficult relationships, financial problems, unwelcomed stressors § Physical factors: stroke, heart attack, cancer, Parkinson's · Consequences of _________________________: loneliness, financial difficulties, loss of independence due to functional disability · Protective factors for depression: marriage

Palliative care

Patient, Family and Caregiver Support for Dementia Patients · At the time of diagnosis, Caregivers need to balance safety with autonomy and address/resolve issues of not driving, not leaving the person home alone, and providing the least restrictive protective physical environment · Strategies to prevent injuries to toddlers can be used to provider a safer physical environment without infantizing persons with AD/dementia: § Place door locks to prevent entry to hazardous areas § Use rug tape to prevent loose scatter rugs § Decrease temp of hot water heater to 120 degrees § Place handrails in bathroom · Older adults need to make plans and decisions for the future, and should be given opportunity to establish advance directives · As disease progresses, the role of the caregiver becomes more active to compensate for the older person's loss of cognition and behavioral symptoms. · Families need support from professional caregivers, especially when they make decisions (selecting life-prolonging treatments that may increase discomfort, or choosing care that is comforting but may hasten death) · Inform caregivers that ________________________ is an option because aggressive care can have a huge burden

Lithium

Pharmacological Treatments for Depression -______________ can be used to treat bipolar disorder § Side effects: fever, bradycardia, hypothyroidism, dry mouth, nausea, vomiting, diarrhea, hypotension, nystagmus, tremor, mental status changes, and seizures Blood levels and overall function must be assessed in initial dosing period

Phenelzine, isocarboxazid, isoniazid, tranylcypromine; selegiline patch

Pharmacological Treatments for Depression · Monoamine Oxidase Inhibitors block MAO in the brain to increase available Norepinephrine, dopamine, and serotonin to reduce depression and control anxiety § _______________________________ · Side effects of Monoamine Oxidase Inhibitors: CNS stimulation, Orthostatic hypotension, dizziness, sedation, nausea, sexual dysfunction, hypertensive crisis § CNS stimulation: mania, agitation, anxiety · Observe for effects and notify provider if they occur § ***Orthostatic hypotension · Nursing Actions: Monitor BP and HR and report to provider · Client Education: change positions slowly § Dizziness § Sedation § Nausea § Sexual dysfunction § Weight gain § HYPERTENSIVE CRISIS results with Monoamine Oxidase Inhibitors from intake of tyramine; it is a severe hypertension as a result of vasoconstriction and stimulation of the heart. · Headache · N/V · Increased Heart Rate · Increased blood pressure · Diaphoresis · Altered level of consciousness · Tyramine Containing Foods: Aged Cheeses, Red Wine, Some beers, Pepperoni, Salami, Avocados, Smoked fish/meats, Figs, Bananas, Pickled Foods · Nursing Actions: administer phentolamine IV or nifedipine, monitor cardiac status and respiratory status, teach client to avoid tyramine foods

Bupropion

Pharmacological Treatments for Depression · ___________ can lower seizure threshold, so it is contraindicated in older adults with seizure disorder. It is usually started at 37.5 mg BID and titrated to 75-100mg BID § Side effects of ___________: agitation, dry mouth, tremor, headache, nausea, excitability, insomnia § ___________, an NDRI, inhibits reuptake of norepinephrine and dopamine to reduce depression, aid in smoking cessation, and reduce symptoms of ADHD § Side effects of ___________ · Dry mouth · Headache · GI distress: nausea, vomiting, anorexia, weight loss · Constipation · Increased heart rate, hypertension, palpitations · Agitation, Excitability, Restlessness/Irritability/tremors · Insomnia · Suppressed Appetite, weight loss: monitor food intake and weight § Nursing Actions for ___________: treat headaches with mild analgesic. Teach the client to notify the provider of intolerable effects. Sip water to treat dry mouth. Increase fiber to prevent constipation. § Precautions for Bupropion · Avoid administering ___________ to clients with seizure disordersbecause it can cause seizures · Increased risk of seizures with ___________ and concurrent SSRI use. Nurses should not administer these medications together · ___________ is contraindicated in clients with Anorexia Nervosa or Bulimia Nervosa due to side effect of suppressed appetite · If ___________ is prescribed but the patient is taking an MAOI, there is a risk of toxicity. A 2-week washout period is required for patients taking MAOIs § Client Education for ___________: therapeutic effects taking 1-3 weeks, full therapeutic effect can take 2-3 months. Take as prescribed. Do not suddenly discontinue due to withdrawal effects. · Observe for headache, dry mouth, GI distress, constipation, increased HR, nausea, restlessness, and insomnia and notify provider if intolerable · Monitor food intake and weight due to appetite suppression · Avoid administering if at risk for seizures § Suicide prevention is facilitated by prescribing only 1 week supply of ___________ for an acutely ill client. Following that, only a 1 month supply (especially if taking a TCA) due to risk of lethal toxic dose. Antidepressant medications can increase suicide risk especially during initial treatment. This is mainly associated with clients under the age of 25.

Mirtazapine

Pharmacological Treatments for Depression · ____________________ can increase appetite in older adults and can be helpful for those with poor food intake. It is started at 15mg at bedtime and titrated to 45mg/day § May be useful in older adults with dementia who suffer from insomnia. The dose should be decreased in those with renal impairment § ____________________ is referred to as an NDRI. It increases release of serotonin and NE § Therapeutic effects of Mirtazapine occur sooner, with less sexual dysfunction than SSRIs § Prescribed at bedtime due to sedation. § Side effects: Weight gain, increased appetite, elevated cholesterol, sleepiness

Alzheimer's disease Association, like support group meetings

Preventing Elder Abuse · The patient with moderate-severe dementia/Alzheimer's disease requires 24 hours of care. Cognitive changes leave them unable to do most ADLs/IADLs · The family needs to seek legal counsel regarding the patient's competency and need to obtain guardianship/durable medical power of attorney when needed · Teach family caregivers to be aware of their own stress and health · Signs of stress include anger, social withdrawal, anxiety, depression, lack of concentration, sleepiness, irritability and physical health problems. · When signs of stress occur, the caregiver should seek help · Reducing family/informal caregiver stress: § Maintain realistic expectations for the person with Alzheimer's disease § Take each day one at a time § Try to find the positive aspects of each incident or situation § Use humor with the person who has Alzheimer's disease § Use the resources of the _____________________ § Explore alternative care settings early in the disease process for use later § Establish advance directive with the Alzheimer's disease patient early in the disease process § Seek respite care periodically for longer periods of time § Take care of yourself. Eat healthy. Get exercise. Get plenty of rest § Be realistic about what you or the patient can do and accept help from others § Use relaxation techniques (meditation and massage) § Seek out clergy or spiritual support § Be mindful about what gives meaning to your life

raising the voice, confronting, arguing, reasoning, taking offense, or explaining.

Preventing Injuries or Accidents in Patients with Alzheimer's disease · Many patients with Alzheimer's disease/dementia wander and get lost. In later stages, they can get agitated and abusive. · The family should be taught the importance of a patient ID bracelet or badge that includes how to contact the primary caregiver · Keep the patient in a room away from stairs/exits and monitor them often. Restlessness can be decreased with frequent walks · If the patient wanders, redirect them · Keep the patient busy with a structured activity schedule: Puzzles, board games, art supplies, and computer games are appropriate § Music and art therapy are helpful activities to keep patients with Alzheimer's disease busy while stimulating cognition · Use the lest-restrictive means for physical restraints. Use waist belts, geri-chairs with lapboards only as a last resort (they cause agitation and restlessness). · Patients can get injured when they don't remember how to use objects. Remove all potentially dangerous objects (knives, drugs, cleaning supplies) · Patients are usually unaware that driving is impaired and want to continue driving. Keep automobile keys secured and remind the patient why they cannot drive · In the late stages of Alzheimer's disease, the patient may have seizures. Teach caregivers what to do if a seizure occurs · If the patient gets agitated, redirect them while speaking softly/calmly. Keep reminding the patient that they are safe with calm, positive statements ("I'm sorry that you are upset" ; "I know its hard" ; "I will have someone stay with you until you feel better.") § AVOID: _____________________________________ § Teach caregivers to not show alarm make sudden movements. If the patient gets agitated, ensure their safety and remind them that you will return later. § Frequent visual checks are needed now because they can pull at IV tubes or nasal cannulas. Provide diversions like stuffed animals § Check weekly for skin breakdown

overstimulation

Preventing and Managing Wandering: § Identify patients most at risk for wandering through observation and history provided by family. § Provide supervision, including frequent checks § Place the patient in an area that provides maximum observation but not in the nurse's station § Use family members, friends, volunteers, and sitters as needed to monitor the patient § Keep the patient away from stairs or elevators § Do not change rooms to prevent confusion § Avoid restraints § Assess and treat pain § Use re-orientation methods and validation therapy as needed § Provide frequent toileting and incontinence care PRN § Prevent _____________________________ (like excess noise) Use soft music and nonglare lighting

Mini-Cog

Screening Tools for Dementia: · The FAST Scale: a screening tool used to determine the presence of dementia § 1 (normal older adult) to 7 (severe dementia) · The ______________: This screening tool for dementia is composed of a three-item recall and a clock drawing test. It is used to easily and quickly detect dementia. You draw a clock, you remember 3 things, and answer questions about orientation (day, time, person, place) § Unsuccessful recall of three items after the clock drawing distractor is classified as probable dementia. § A positive Mini-Cog indicates the need for further assessment by a geriatrician or mental health professional. § The Mini-Cog takes approximately 3 minutes to administer. § It is not influenced by the patient's education, culture, or language.

start sympathomimetic treatment, cooling blankets, anticonvulsants, artificial ventilation. Teach client to notify provider of symptoms

Selective Serotonin Reuptake Inhibitors (SSRI) -Paroxetine, sertraline, citalopram, fluoxetine, escitalopram, fluvoxamine · Serotonin Syndrome can begin 2-72 hours after SSRI treatment and can be lethal. The more SSRIs and other antidepressants taken, the greater the risk. § Signs/Symptoms: Mental confusion, Abdominal pain, Diarrhea, High Fever, Hyperreflexia (tremors, jerking), Diaphoresis (perfuse sweating), Tremors · Confusion, agitation, poor concentration, hostility · Disorientation, hallucinations, delirium · Seizures · Tachycardia leading to cardiovascular shock · Labile BP · Diaphoresis · Fever leading to hyperpyrexia · Incoordination, hyperreflexia, tremors · Coma leading to apnea (and death eventually) § Nursing actions: _________________________________

Paroxetine, sertraline, citalopram, fluoxetine, escitalopram, fluvoxamine

Selective Serotonin Reuptake Inhibitors (SSRIs): · Start with a low dose · Side Effects of Selective Serotonin Reuptake Inhibitors (SSRIs): hyponatremia, risk of GI bleeding, and, nausea, diarrhea, headache, erectile dysfunction, insomnia, somnolence · Selective Serotonin Reuptake Inhibitors (SSRI) selectively block the reuptake of serotonin in the synaptic space to reduce depression and control anxiety and obsessions § Generally first line treatment for depression § __________________________________ · Possible side effects of Selective Serotonin Reuptake Inhibitors § Nausea, headache, rash § CNS Stimulation: agitation, insomnia, anxiety · Nursing actions: teach relaxation techniques to promote sleep · Client Teaching: notify the provider for possible dosage reduction, take medication in the morning, avoid caffeine § Weight changes: weight loss in early treatment; weight gain in long-term · Nursing actions: monitor client's weight and encourage client to exercise regularly and eat a healthy, well-balanced diet § Hyponatremia: · Nursing actions: obtain baseline sodium, monitor level throughout treatment, know it mostly occurs in older adults taking diuretics § Gi bleeding: use cautiously in clients with a history of ulcers or taking anticoagulants § Bruxism: grinding of teeth (may notice sore/tender jaw, or family may notice) · Report this to the provider. Use a mouth guard. § Sexual dysfunction, anorgasmia, impotence, decreased libido · Client education: observe for effects and notify provider if not tolerable, doctor may lower dose or use another med (atypical antidepressant) · Utilize ways to manage sexual dysfunction (lowering dosage, discontinuing med, using drugs to improve sexual function) § Sleepiness, faintness, lightheadedness: teach client to avoid driving § Risk of Extra-pyramidal symptoms (EPS) § risk of bone fracture § Withdrawal syndrome: headache, nausea, visual disturbances, anxiety, dizziness, tremors · Educate the client to taper the dose gradually when discontinuing medication.

Delirium

Signs and Symptoms of ____________________ in the Older Adult · 1) Reduced LOC: observe the patient, does he/she fall asleep during routine patient care. · 2) Disorientation: Assess orientation to time, place, & person. Disorientation is common in acutely ill older adults, but often reorientation efforts in those without delirium to current circumstances are successful. An older adult with delirium is often unable to be reoriented. · 3) Short term memory impairment: Sudden onset loss of recent memory is common in delirium. Ask the older adult about his/her care earlier in the day. Patients who forget family visits, bathing or showering, or eating breakfast may have memory impairment. · 4) Agitation: patient may not be able to tolerate an IV line or urinary catheter. He/she may attempt to pull out these and other medical devices or otherwise refuse needed care. Agitated patient's are at risk for receiving sedative/hypnotic medications that have the potential to further increase orientation, memory and LOC. · 5) Attention impairment: The pt may not be able to maintain attention or complete a task. Ask the pt to spell a word backwards or subtract 7 from 100. · 6) Perceptual disturbance: Delirious patient's may experience visual or auditory hallucinations. · 7) Delusions: A persistent false thought may be present and difficult to dispel in the older adult with delirium. These delusions are often related to disorientation and memory impairment and can fluctuate widely during the course of the day. 8)Sleep-wake cycle disturbance:older patient's with delirium will often sleep soundly during the day and experience significant nighttime awakenings

parietal lobe

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Central Nervous System includes the cerebral cortex, basal ganglia, diencephalon, cerebellum, brain stem, and spinal cord. § The brain is divided into right/left halves and further divided into 4 lobes: temporal, frontal, parietal, and occipital § The _____________ of the brain integrates sensory information, such as taste, pain, temperature · sensory alterations, spatial relationship problems.

occipital lobe

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Central Nervous System includes the cerebral cortex, basal ganglia, diencephalon, cerebellum, brain stem, and spinal cord. § The brain is divided into right/left halves and further divided into 4 lobes: temporal, frontal, parietal, and occipital § The _______________ processes visual information · Visual disturbances

temporal lobe

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Central Nervous System includes the cerebral cortex, basal ganglia, diencephalon, cerebellum, brain stem, and spinal cord. § The brain is divided into right/left halves and further divided into 4 lobes: temporal, frontal, parietal, and occipital § The ________________ is responsible for language (Wernicke's area), memory, hearing, perception, and recognition · Speech and hearing

Frontal lobe

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Central Nervous System includes the cerebral cortex, basal ganglia, diencephalon, cerebellum, brain stem, and spinal cord. § The brain is divided into right/left halves and further divided into 4 lobes: temporal, frontal, parietal, and occipital § _____________________ functions in language (Broca's area), motor function, judgement, problems solving, impulse control, reasoning, memory, and executive function (ability to plan/think abstractly) · personality, speaking, memory, reasoning & concentration.

somatic nervous system

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Peripheral Nervous System consists of the cranial nerves, spinal nerves, the somatic and autonomic nervous system, and the reflex arc § The _________________ is the link between the brain through the spinal cord to the muscles and sensory receptors. It is responsible for movement and receiving messages § Conditions of the PNS: motor, sensory, autonomic disorders

autonomic nervous system

The Neurological System · The human nervous system controls consciousness, cognition, moral reasoning, and behavior. · The functional health of older adults is dependent on a healthy functioning neurologic system · The Peripheral Nervous System consists of the cranial nerves, spinal nerves, the somatic and autonomic nervous system, and the reflex arc § The ___________________ maintains homeostasis within the body and is divided into the parasympathetic and sympathetic nervous system. It controls the heart, size of blood vessels, blood pressure, contraction, and relaxation of smooth muscle in various organs, visual accommodation, pupillary size, and secretions from exocrine and endocrine glands § Conditions of the PNS: motor, sensory, autonomic disorders

B. Hallucinations D. Urinary incontinence E. Difficulty eating

The nurse Assesses an older adult with a diagnosis of severe, late stage Alzheimer's disease. Which assessment findings would the nurse expect for this client. (SATA) A. Acute confusion B. Hallucinations C. Wandering D. Urinary incontinence E. Difficulty eating

elevating HOB to 30 degrees for an hour after feeding

Transfer to an Acute-Care site · Feeding Tubes: § The need for feeding tubes may be avoided by promoting eating and preventing food refusal. Caregivers should sit, make eye contact, chat, and make eating an important and pleasurable component of long-term institutional care § Natural feeding can resume after tube feedings. An individualized plan based on target weight and eating abilities should be discussed by the nurse and healthcare team. Natural feeding can begin when the tube is in place until routine feeding habits are reestablished. Then the tube can be removed § Placement on NG tubes increase risk of aspiration pneumonia (_____________________________ can decrease this risk) § Permanent tube feeding is not recommended for those with advanced AD, even those who choke on food/fluids. Older people with advanced AD do not feel the desire to eat or drink. Body function are shutting down during the dying process, and food and liquids are no longer needed. · Dehydration may be beneficial during the dying process because it decreases sensation of pain, prevents edema, prevents excess respiratory secretions, and prevents vomiting and diarrhea. BUT it can cause dryness of the mouth and lip (use Chapstick, or ice chips)

nursing home does not have enough staff to administer and monitor IV therapy, lack of diagnostic services, and pressure from staff/family.

Transfer to an Acute-Care site · Many times, nursing home residents are transferred to a hospital because the __________________ · Once in the hospital, older adults with dementia are at risk for complications (delirium, tube feeding, relocation stress, and dying). § Problems of delirium are associated with prolonged hospitalization, nursing-home placement, accelerated decline in cognitive/physical function, and death. Older delirious persons often refuse care and are subject to sedating medications and restraints · When discussing transferring, nurses need to help the family understand the differences between reversing an acute-care problem (in a healthy person) and extending the dying process in a person with AD § Heart surgery can be too much · A transfer to an acute care unit means that older people will be vulnerable to nosocomial infections and care by staff training in critical care (not dementia). Many older adults come into the hospital continent, and leave incontinent. Most older adults hospitalized for acute medical illness or surgical illness decline in the ability to perform ADLs

interruptions with transmitting into between neurons , protein buildup causing death of neuron, inflammation

What Happens to the Brain During Dementia? · There are multiple causes of dementia that affect the brain in different ways and determine the symptoms that a person experiences: § ______________________________________ · All cells are like miniature factories, producing thousands of proteins with specific functions to keep the cell alive. A malfunction can occur if a protein is altered, or if too much or too little is made, resulting in cell death. · !!!!!!!!!!!! Neuron death is the main cause of dementia and is often related to malfunctions in the communication system that a neuron needs to survive. · If the immune system of the brain is too active and causes inflammation, this can also damage cells. Unlike most cells, when neurons die, other cells do not divide and replace them. Therefore most dementias are progressive and cannot be reversed.

Do Not Resuscitate

__________________________: · For people with late stage dementia, CPR should not be offered. If the person does not have a DNR, the DNR decision should be discussed with the surrogate decision maker · Older adults who have had CPR may sustain rib fractures, damaged airways, internal bleeding, brain damage, often resulting in a prolonged/painful death · A DNR order often will spare the older adult from living in an uncomfortable state for the remainder of their lives · Education should be given to families who make the ultimate decision about DNR for older persons who can't do it themselves. · Older adults designated as DNR should place large, clear instructions on the fridge, notify neighbors, family and friends, and a "No CPOR" card in their wallet

more at risk for development of acute illness or exacerbation of chronic illness.

· An older adult is considered to be in major depression when the presence of 4 of the following persist for at least 2 weeks along with changes in social relationships and daily function: § Significant weight loss/gain or changes in appetite § Disturbances in sleep patterns § Noticeable agitation or slowness § Fatigue or loss of energy § Inappropriate feelings of worthlessness or guilt § Inability to concentrate or make decisions § Recurrent thoughts of suicide or death · **REMEMBER: Chronic depression has been shown to decrease immune function and therefore depressed older persons are _____________________________

Dysthymia

· Depression is a clinical syndrome characterized by low mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss or guilt ; it is the mental health problem of greatest frequency and magnitude in the older population. -___________________________: persistent feelings of sadness that don't quite meet the criteria for clinical depression with few physical symptoms. This condition involves less-severe depression with long-term, chronic symptoms that don't disable the person (but do keep them from enjoying life) § May not be disabling, but may keep the pt from feeling well or enjoying life to its fullest. § Management: increased socialization, traditional psychotherapy, close monitoring to ensure symptoms don't develop into depression

soy products, folate, vitamin b12, C, and E

· Health Promotion and Maintenance of Alzheimer's disease: § Healthy lifestyle § Well-balanced diet: ______________________ § Walking, swimming, exercise

Aerobic exercise

· Healthy Aging Tips for Mental Health § Maintain active social life and engage in plenty of interesting conversations § Read newspapers, magazines, and books § Play thinking games like scrabble, computer games, cards, and trivial pursuit § Take a course on a subject that interests you § Develop a new hobby § Learn a second language or how to play an instrument § Watch "question and answer" game shows on TV and play along with contestants § Keep stress under control with exercise, relaxation, and medications (stress hormones can damage nerves) § Stay healthy and active. ___________________ increases blood flow to the brain and helps support new neural and vascular connection

· Place complete outfits for the day on hangers; have the patient select one to wear

· Minimizing Behavioral Problems For Patients With Alzheimer's Disease At Home: § Carefully evaluate the patient's environment for safety · Remove small area rugs · Replace tile floors with non-slippery ones · Arrange furniture to maximize walking safety · Minimize clutter inside and outside · Install nightlights in the patient's room, bathroom, and hallway · Install and maintain smoke alarms, fire alarms, and natural gas detectors · Install safety devices in the bathroom (rails) · Install alarm systems or bells on outside doors; place safety locks on doors and gates · Ensure that door locks can't be easily opened · Keep a lock on thermostats and water heaters · Place the mattress on the floor · Secure electrical cords to baseboards · Place a shower chair in the tub · Enroll in the Safe Return Home program § Help the patient with mild-stage disease remain oriented to the best extent · Place single-date calendars in the patient's room and kitchen · Use large-face clocks with neutral background § Communicate with the patient based on their ability to understand: · Explain activities immediately before they need to carry it out · Break complex tasks into simple steps § Allow and encourage the patient to be independent in ADLs to best extent: ___________________________________________________ · Develop and maintain a predictable routine § When problem behaviors occur, divert patient to another activity; minimize excess stimulation: · Take patient on outings when crowds are small · If crowds can't be avoided, minimize time around them. At family visits (events), provide a quiet room for them to rest § Arrange for a day-care program to maintain interaction and provide respite for home caregiver

caffeine, fava beans, chocolate, and ginseng

· Monoamine Oxidase Inhibitors block MAO in the brain to increase available Norepinephrine, dopamine, and serotonin to reduce depression and control anxiety § Phenelzine, isocarboxazid, isoniazid, tranylcypromine; selegiline patch · Side effects of Monoamine Oxidase Inhibitors: CNS stimulation, Orthostatic hypotension, dizziness, sedation, nausea, sexual dysfunction, hypertensive crisis · Monoamine Oxidase Inhibitor Contraindications: § Monoamine Oxidase Inhibitors are contraindicated in clients taking SSRIs, pheochromocytoma, heart failure, cardiovascular disease, cerebrovascular disease, severe renal insufficiency § Use cautiously in clients with diabetes or seizure disorders; those taking TCAs · MAOI Interactions: § Use of Monoamine Oxidase Inhibitors with of OTCs (ephedrine/amphetamine) can lead to HTN crisis. § Avoid SSRIs, TCAs, SNRI's, and Antihypertensives when taking Monoamine Oxidase Inhibitors § Use of Monoamine Oxidase Inhibitors with antihypertensives may cause hypotension § Avoid __________________________....may also cause hypertension with Monoamine Oxidase Inhibitors § Buspirone + MAOI = psychosis, agitation, seizures § Antidiabetics + MAOI = hypoglycemia § Tegretol + MAOI = fever, hypertension, seizures · Client Education for Monoamine Oxidase Inhibitors: § Due to risk of hypertensive crisis, avoid foods with tyramine (avocados, figs, fermented/smoked meats, liver, dried/cured fish, cheese, beer, wine, protein dairy supplements) § Due to the risk of medication interactions, avoid all medications, including OTC, without discussing them with your doctor § change positions slowly due to orthostatic hypotension

Bereavement

· Most older adults experience the loss/death of loved ones · Symptoms of pathological grief in older adults: preoccupation with death, extensive guilt, overwhelming sense of loss/worthlessness, marker psychomotor retardation, functional impairment · ____________________: § Greif after the loss of a loved one is normal, but grief that lasts for a very long time or is unusually severe requires further evaluation/treatment § *Some define grief as sadness turned outward (crying in public, talking about it), while depression is sadness turned inward 9isolation, separation from others) § Factors that can affect the duration and course of grieving: · Centrality of the loss: the closer the person/pet/object is to the one that was lost, the harder the loss will be to bear. · Health of the survivor: an older person with good mental/physical health will better cope with the loss of a loved one and complete grief. Unresolved issues from the past, feelings of ambiguity toward lost one, and unresolved/incomplete coping with other loses can complicate the grieving process · Survivor's religious or spiritual-belief system: Religion can have a positive influence on the grieving process · History of substance abuse: use of drugs or alcohol to cope with losses is never good · Nature of the death: sudden deaths are more difficult and prolong grieving; and can result in a PTSD reaction

pseudodementia

· Older adults can prepare for age-related changes by developing coping mechanisms to accept challenges. § !!!! Most older adults successfully adjust to the challenges of aging, but nurses must be alert to the symptoms of depression that will present differently in the older person. Vague physical decline and somatic complaints may be the only clues of underlying depression § Certain medications (sleeping pills, tranquilizers, pain medications) can cause symptoms similar to dementia (confusion, lack of interest, memory impairment), but are not true dementia. These symptoms are called false dementia or __________________________ · Education levels of older adults has increased significantly; higher education levels are associated with increased travel, recreation, income, and opportunities for personal growth and development. · Positive mental health is a necessary component of successful aging: positive evaluation of life; positive emotions like happiness, feelings of peace, interests beyond the self, and life satisfaction combine to form "well-being · Mental Health: Themes: § Mental health is fundamental to health § Mental illnesses are real health problems § The efficacy of mental health treatments is well documented § Mind and body are inseparable § There is a serious shortage of trained mental health professionals to meet the need for services § Stigma is a major obstacle preventing older people from getting help

seizure disorder or risk for seizures (head injury, brain tumor)

· Selective Serotonin Reuptake Inhibitors (SSRI) selectively block the reuptake of serotonin in the synaptic space to reduce depression and control anxiety and obsessions -Paroxetine, sertraline, citalopram, fluoxetine, escitalopram, fluvoxamine · SSRI Precautions § Fluoxetine and paroxetine can increase risk of birth defects with SSRIs. § SSRIs are contraindicated with TCAs and MAOIs. Risk of serotonin syndrome!! § Must have 2 week wash out period for MAOI. Must be off MAOI for 2 weeks before starting new SSRI due to risk of serotonin syndrome. § Caution use in clients with liver or renal dysfunction, GI bleeding, cardiac disease, diabetes, ulcers, and seizure disorders. · If they have a ____________________________, the client should NOT take an SSRI · SSRI Drug Interactions: MAOIs, TCAs, St. Johns Wort, warfarin, lithium, NSAIDS, § St. Johns Wort, Buspirone, TCAs + SSRI = serotonin syndrome § Warfarin + SSRI = check PT/INR and frequently assess for bleeding § NSAIDs and anticoagulants increase the risk of bleeding (GI bleeding) with SSRIs § Lithium + SSRI = increased levels of lithium (toxicity risk) when combined § MAOI + SSRI = hypertensive crisis § Alcohol, benzodiazepines + SSRI = increased sedation § Antiepileptics + SSRI = lowered seizure threshold · Client Education for Selective Serotonin Reuptake Inhibitors (SSRI): § Adverse effects can include nausea, headache, and CNS stimulation (agitation, insomnia, anxiety) § Be aware that sexual dysfunction can occur and notify the doctor if intolerable § Observe for manifestations of serotonin syndrome. If any occur, withhold the medication and call the doctor § Avoid use of St. John's wort, which can increase risk of serotonin syndrome § Follow a healthy diet and exercise regimen because weight gain can occur with long-term use § Utilize ways to manage sexual dysfunction (lowering dosage, discontinuing med, using drugs to improve sexual function)

alcohol

· Serotonin Norepinephrine Reuptake Inhibitors (SNRI's) increase the levels of serotonin and norepinephrine in the synaptic cleft to reduce depression, relive pain/neuropathy, and relive anxiety § Venlafaxine, duloxetine, desvenlafaxine, levomilnacipran · Drug Interactions Serotonin Norepinephrine Reuptake Inhibitors (SNRI's): § MAOIs = serotonin syndrome § NSAIDS, anticoagulants = increased bleeding risk § Alcohol - CNS effects § Kava, Valerian = CNS depression § St. John's wort = serotonin syndrome · Nursing Actions for Serotonin Norepinephrine Reuptake Inhibitors (SNRI's) § Adverse effects include nausea, insomnia, weight gain, diaphoresis, and sexual dysfunction. Caution administering in clients who have a history of hypertension § Teach clients to avoid abrupt cessation of SNRIs and decrease dose gradually (withdrawal can occur) § Monitor weight less and food intake § Monitor vitals for HTN and tachycardia § Avoid driving due to dizziness and blurred vision § Utilize ways to manage sexual dysfunction (lowering dosage, discontinuing med, using drugs to improve sexual function) § Observe for manifestations of serotonin syndrome. If any occur, withhold the medication and call the doctor § Duloxetine should not be used in clients with hepatic disease or who consume large amounts of ___________________

Venlafaxine, duloxetine, desvenlafaxine, levomilnacipran

· Serotonin Norepinephrine Reuptake Inhibitors (SNRI's) increase the levels of serotonin and norepinephrine in the synaptic cleft to reduce depression, relive pain/neuropathy, and relive anxiety § _________________________________________ · Side effects § Anorexia, nausea, weight loss § HTN, tachycardia § tremors § Dizziness, blurred vision § Agitation § Dry mouth, sweating § Hyponatremia § Sexual dysfunction § Headache, insomnia (sleep disturbance, anxiety § GI upset, § Withdrawal syndrome (feeling very sick/nauseated, headache, anxiety, tremors) § Serotonin syndrome · Contraindications to Serotonin Norepinephrine Reuptake Inhibitors (SNRI's): § Avoiding taking during the 3rd trimester of pregnancy § They are contraindicated in clients taking SSRIs, MAOIs, or TCAs. Must have 2 week washout before starting an MAOI § Precaution with older adults

Brain weight is further reduced and there is marked atrophy of the cerebral cortex and loss of cortical neurons

· The older adult's brain in the presence of Alzheimer's disease: changes of aging are greatly accelerated. ____________________________ is further reduced and there is marked atrophy of the cerebral cortex and loss of cortical neurons . · Neuropathological Criteria for Alzheimer's Disease: § Presence of 2 abnormal structures: 1. neuritic plaques and 2. neurofibrillary tangles; as well as vascular degeneration § Neurofibrillary tangles are composed of tissue that impairs the ability of impulses from being transmitted from neuron to neuron; tau protein is in the tangles § Neuritic plaques are composed of degenerating nerve terminals and contain beta amyloid (these proteins accumulate and form the neurotoxic plaques that impair neuronal transmission § Vascular degeneration is increased in patients with dementia and accounts for some loss of function of nerve cells and cognitive decline · Alzheimer's Disease disrupts 3 processes that keep neurons healthy: 1. Communication 2. Metabolism 3. Repair § As a result, nerve cells are destroyed or die, causing memory failure, personality changes, problems carrying out ADLs, and other deficits

· Old age · CAD · Liver, renal (urinary retention/obstruction), or respiratory disease · Angle closure glaucoma · BPH · Hyperthyroidism · Diabetes

· Tricyclic antidepressants increase levels of norepinephrine and serotonin in the synaptic cleft, blocks histamine receptor, blocks ACh receptor to reduce depression, relive severe pain, and prevent panic attacks § Imipramine, doxepin, nortriptyline, amoxapine, trimipramine, desipramine, clomipramine · Side effects of Tricyclic antidepressants: Orthostatic hypotension, anticholinergic effects (dry mouth, blurred vision, urine retention), sedation, sweating, increased appetite, sexual dysfunction, decreased seizure threshold, toxicity - Tricyclic antidepressant (TCA) Precautions § Tricyclic antidepressants are contraindicated in patients with Seizure Disorders, or history of MI § Use Tricyclic antidepressants cautiously in those with Hx of suicide attempts § Use Tricyclic antidepressants with caution in clients with: - - - - - § TCA Drug Interactions: MAOIs, antihistamines, anticholinergics, beta blockers, alcohol, benzodiazepines, opioids · MAOI + TCA = HYPERTENSION, high fever, convulsions, death · St. John's Wort, tramadol + TCA = seizures, serotonin syndrome · Clonidine, epinephrine + TCA = severe hypertension · Acetylcholine blockers + TCA = paralytic ileus · Alcohol and carbamazepine + TCA = blocks antidepressant action, increased sedation · Cimetidine and bupropion + TCA = increased TCA blood levels and increased side effects · Antihistamines can. Have added anticholinergic effects § Client Education for Tricyclic antidepressants: · Change positions slowly to minimize dizziness from orthostatic hypotension To minimize anticholinergic effects, chew sugarless gum, eat foods high in fiber, and increase fluid intake to 2-3L/day from food/beverages

multi-infarct dementia

· Vascular Dementia is a type of dementia that progresses with stepwise deterioration, executive dysfunction, and gait changes. It usually presents abruptly and is thought to be caused by cardiovascular factors causing blood-vessel blockage/damage leading to small strokes and bleeding into the brain -Vascular Dementia (multi-infarct dementia) results from strokes or vascular diseases that decrease blood flow to the brain · One type of vascular dementia, called ______________________________, is caused when blood vessels become blocked, for example during a stroke.

small-vessel disease

· Vascular Dementia is a type of dementia that progresses with stepwise deterioration, executive dysfunction, and gait changes. It usually presents abruptly and is thought to be caused by cardiovascular factors causing blood-vessel blockage/damage leading to small strokes and bleeding into the brain -Vascular Dementia (multi-infarct dementia) results from strokes or vascular diseases that decrease blood flow to the brain · The other type, _____________________________ occurs when the walls of blood vessels are damaged causing little bleeds. This leads to localized damage, and disrupted blood flow, throughout the brain.

Respite

· _________ provides family caregivers with the relief necessary to maintain their own health, bolster family stability, keep marriages intact, and avoid or delay much more costly nursing home or foster care placement. · ____________, however, is in short supply or inaccessible for all age groups.

Depression

· ________________ is a clinical syndrome characterized by low mood tone, difficulty thinking, and somatic changes precipitated by feelings of loss or guilt ; it is the mental health problem of greatest frequency and magnitude in the older population. · ______________________: despondent mood marked by decreased energy, feeling worthless and guilt, problems with concentration, and thoughts of death or suicide can lead to increased disability, premature death, increased morbidity, cognitive decline, increased risk of institutionalization, and decreased in quality of life § Increased risk if the person has illnesses or loss of function § The mental health problem of greatest frequency and magnitude in the older population. § Risk increases with decline in function occurs in aging patient. § Depression in older adults is often undetected and untreated. § Depression may be seen as a group of disorders with variable severity. § Depression can include mild sadness over long periods of time, brief period of sadness, intense reaction to loss, severe psychotic depression (hallucinations/bizarre behavior), profound regression of pseudodementia (cognitive impairment and tunning the world out) · Diagnosis of dementia can cause depression · Older adults may barely cooperate with mental health testing, frequently stating "I don't know" · They may appear hopeless and slow to respond; with flat affect and little motivation for tasks

Cognition

· ________________ is a complicated process by which information is learned, stores, retrieved, and used by and individual § Cognitive processing supports reasoning, problem solving, remembering, interpreting, and communicating § Methods for Coping with age-related cognitive changes: · Making lists, posting appointments on calendars, and writing notes to self · Learning memory training and memory-enhancement techniques · Playing computer games that emphasize eye/hand coordination and memory of shapes, colors, and objects · Keeping mind challenged and mentally active (reading, crossword puzzles, playing bridge) · Using assistive devices, (pill boxes) and reliance on habit (preprogrammed telephones, parking in the same place) to reduce chances of forgetting vital information · Seeking support and encouragement from others · Staying positive and hopeful for the future (laughing at oneself when appropriate) § Some older adults with severe cognitive deficits (lacking insight to problems) can engage in behaviors that are unsafe (driving, cooking)

Confusion Assessment Method (CAM) -· The diagnosis of delirium requires the presence of features 1 and 2, and either 3 or 4.

· ________________: This tool identifies the presence or absence of delirium. The short version assesses four key features that distinguish delirium from other types of cognitive impairment. § Feature 1: Acute onset and fluctuating course § Feature 2: Inattention § Feature 3: Disorganized thinking § Feature 4: Altered level of consciousness · The diagnosis of delirium requires the presence of __________________________________________ · The tool can be easily administered by the bedside clinician, who will then ensure that the delirious patient receives timely diagnosis and treatment for the cause of the confusion. · Can be administered in < 5 minutes. · Closely correlates with DSM-IV criteria for delirium. · The most widely used instrument for diagnosing delirium by internists and non-psychiatric clinicians

Delirium

· ________________: an acute disorder of cognition that affects functional independence. § Any sudden changes in mental status need to be aggressively evaluated (Dementia does not develop overnight). · ________________ may be reversible, but it can result in irreversible changes · ________________ may indicate a decreased reserve capacity of the brain (an increase risk for dementia). · Approximately 15 - 60 % of elderly patients experience a ________________ prior to or during a hospitalization but the diagnosis is missed in up to 70% of cases.

Dementia

· ___________________ is a syndrome whose signs and symptoms may be the result of several acquired, progressive, life-limiting disorders that erase memory and the person's usually way of being in the world. The person with dementia has a chronic illness and a terminal illness · ___________________: chronic confusional state; a general, progressive loss of brain function and impaired cognition. § ___________________ affects a person's ability to learn not information and eventually impairs language, judgement, and behavior. As the disease progresses, the patient's functional ability declines, and death occurs as a result of complications of decreased mobility § First, they lose the ability to independently perform ADLs and eventually they become totally dependent in all aspects of self-care § It can cause older adults to act in ways that would makes others uncomfortable or embarrass them if they had their normal faculties § Functional Impairment is a primary consequence of dementia § Apraxia: the inability to carry out learned and purposeful movements, and interferes with ability to follow simple commands § Agnosia: the inability to recognize objects; it causes functional impairment and predisposes to safety hazardous (eating inedible items) § Anomia: severe problems naming objects or finding words § Can affect different areas of the brain and different levels of the cortex, there is no uniform course and no predictability. § Memory loss and impairment in Alzheimer's disease is associated with damage to the hippocampus and the temporal and parietal lobes. · It is associated with accumulation of two proteins - amyloid and tau - into plaques and tangles in the brain · Symptoms can vary.

Alzheimer's Disease

· ___________________ is a type of dementia that presents with language, memory, and visual spatial disturbances (decline in multiple cognitive abilities). It has an insidious onset; and may have a genetic, lifestyle, and environmental component. It is associated with plaques and tangles in the brain § Early dementia, ___________________ type, presenile dementia occurs with the onset of ___________________ in ages 40-50s § It is characterized by slow, progressive cognitive and functional decline. § Can result in abnormal reflexes, seizures, myoclonic jerks, rigidity, loss of ability to walk, loss of ability to stand § Preclinical Stage of ___________________: this stage of ___________________ occurs before memory loss and functional impairments occur. In this stage, changes in biomarkers (beta-amyloid proteins) are thought to occur, but there are no reliable diagnostic testing criteria with this stage. § Early in the disease, pt. may have difficulty remembering names and recent events. § Later they demonstrate symptoms that include impaired judgment, disorientation, confusion, behavior changes, and trouble speaking, swallowing and walking.

Stage 1 Early-Mild

· ________________________: in this stage of dementia and AD, the older adult is usually still able to function independently, but may complain of word-finding difficulties; memory problems (remembering names of new friends); challenges performing work duties; losing or misplacing objects; or trouble planning/organizing daily activities § Independent in ADLs § Denies presence of symptoms § Forgets names, misplaces household items § Has short-term memory loss/lapses and difficulty recalling new information § Shows subtle changes in personality and behavior § Has trouble remembering names of new people § Loses initiative and is less engaged in social relationships § Has mild impaired cognition and problems with judgement/attention/concentration § Demonstrates decreased performance, especially when stressed § Unable to travel alone to new destinations § Often has decreased sense of smell § Short-term memory loss may not be noticeable to others

Dementia

· _________________________ is a syndrome that must include the presence of cognitive or behavioral symptoms that: § Interfere with the ability to function at work or at usual activities and § Represent a decline from previous levels of functioning and performance and § Are not explained by delirium or major psychiatric disorders § Cognitive impairment is present and diagnosed through a combination of history supplied by the older person and/or caregiver and objective cognitive assessment, including bedside mental status examination, or neuro-psychological testing. neuro-psychological testing should be done when the history and bedside exam cannot provide a confident diagnosis § !!!!!!!!!!!! The cognitive or behavioral impairments involves a minimum of 2 of the following: · Memory: Impaired ability to acquire and remember now information-symptoms include repetitive questions or conversations, misplacing personal belongings, forgetting events/appointments, getting lost on a familiar route · Reasoning and Judgment: Impaired reasoning and handling of complex tasks, poor judgement- symptoms include poor understanding of safety risks, inability to manage finances, poor decision making ability, inability to plan complex or sequential activities · Visual Perception: Impaired visuospatial abilities- symptoms include inability to recognize facies or common objects or to find objects in direct view despite good acuity, inability to operate simple implements, or orient clothing to the body · Communication and Language: Impaired language functions (speaking, reading, writing)- symptoms include difficulty thinking of common words while speaking, hesitations speech, spelling, and writing errors · Attention Span: Changes in personality, behavior, or comportment- symptoms include uncharacteristic mood fluctuations (agitation, impaired motivation, initiative, apathy, loss of drive, social withdrawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive behaviors, socially unacceptable behaviors

Vascular Dementia

· ____________________________ is a type of dementia that progresses with stepwise deterioration, executive dysfunction, and gait changes. It usually presents abruptly and is thought to be caused by cardiovascular factors causing blood-vessel blockage/damage leading to small strokes and bleeding into the brain § ____________________________ (multi-infarct dementia) results from strokes or vascular diseases that decrease blood flow to the brain · Blood carries all the oxygen and nutrients to the brain and there are thousands of blood vessels that feed the different regions. · If blood flow is reduced, cells in the brain begin to starve and die. This can lead to vascular dementia. · One type of vascular dementia, called multi-infarct dementia, is caused when blood vessels become blocked, for example during a stroke. · The other type, small-vessel disease occurs when the walls of blood vessels are damaged causing little bleeds. This leads to localized damage, and disrupted blood flow, throughout the brain. · Diagnostic criteria for ____________________________: abrupt onset of dementia, focal neurologic findings (abnormal reflexes or nerve functions), low-density areas (vascular changes in white matter), presence of many strokes on CT or MRI · Other Characteristics: fluctuation of impairment, unchanged personality, emotional lability, and temporal relation between a stroke and development of dementia § Infarcts can weaken extremities, exaggerate reflexes, or cause gait abnormalities § Very impulsive, aggressive, inappropriate behavior Management:controlling

Stage 2 Middle-Moderate

· _______________________________: in this stage of dementia and AD, the older adult may forget events in their personal life, feel moody or withdrawal, express confusion with time, become lost in familiar places, experience changes in sleep, and changes in personality § Impairment in all cognitive functions (such as mental arithmetic) § Demonstrates problems with handling or unable to handle money/finances § Is disoriented to time, place, and event § Personality/behavioral changes: appearing withdrawn or subdued, especially in social or mentally challenging situations; compulsive' repetitive actions § Forgetting events of one's own history § Possibly depressed or agitated § Increasingly dependent in ADLs § Has visuospatial deficits; difficulty driving and gets lost § Speech/Language deficits; less talkative, decreased use of vocabulary, increasingly nonfluent, eventually aphasic § Incontinent often § Has episodes of wandering; trouble sleeping § Clinical findings are noticeable to others