Foundations: Varcarolis Ch 17 Cognitive Disorders

Read Integrative Therapy pg. 395

Ginkgo Biloba

Read Table 17-7 pg. 389

Guidelines for Communication with People with Dementia

Read Table 17-2 pg 376

Potential Nursing Diagnosis for the Confused Patient

Causes of Delirium (Tumor) Box 17- 1

Primary Cerebral

hypervigilance pg. 374

patients are extraordinarily alert, and their eyes constantly scan the room; they may have difficulty falling asleep or may be actively disoriented and agitated throughout the night.

Causes of Delirium (Postoperative States Drug Intoxication and Withdrawals) Box 17-1

alcohol, anxiolytics, opioids, and central nervous system stimulants (e.g. cocaine and crack cocaine)

agraphia pg.384

inability to read or write

hypermetamorphosis pg. 384

manifested by touching of everything in sight

Read Table 17-10 pg. 392

Patient and Family Teaching: Guidelines for Care at Home

Assessment Guideline Delirium pg. 375

1. Assess for acute onset and fluctuating levels of consciousness, which are key in delirium. 2.Assess the person's ability to attend to the immediate environment, including responses to nursing care. 3. Establish the person's normal level of consciousness and cognition by interviewing family or other caregivers. 4.Assess for past cognitive impairment-especially an exiting dementia diagnosis-and other risk factors. 5.Identify disturbances in physiological status, especially infection, hypoxia, and pain. 6. Identify any physiological abnormalities documented in the patient's record. 7. Assess vital signs, level of consciousness, and neurological signs. 8. Assess potential for injury, especially in relation to potential for falls and wandering. 9. Maintain comfort measures, especially in relation to pain, cold, or positioning. 10. Monitor situational factors that worsen or improve symptoms. 11. Assess for availability of immediate medical interventions to help prevent irreversible brain damage. 12. Remain nonjudgemental. Confer with other staff readily when questions

Assessment Guidelines for Dementia

1. Evaluate the person's current level of cognitive and daily functioning. 2. Identify any threats to the person's safety and security and arrange their reduction, 3. Evaluate the safety of the person's home environment (e.g. with regard to wandering, eating inedible objects, falling, engaging in provocative behaviors toward others). 4. Review the medications (including, herbs, complementary agents) the patient is currently taking. 5. Interview family to gain a complete picture of the person's background and personality. 6.Explore how well the family is prepared for and informed about the progress of the person's dementia, depending on cause (if known). 7. Discuss with the family members how they are coping with the patient and their main issues at this time. 8.Review the resources available to the family. Ask family members to describe the help they receive form other family members, friends, and community resources. Determine if caregivers are aware of community support groups and resources. 9. Identify the needs of the family for teaching and guidance (e.g. how to manage catastrophic reactions, lability of mood , aggressive behaviors, and nocturnal delirium and increased confusion and agitation at night (sundowning)

Basic Medical Workup for Dementia Box 17-3

>Chest and skull radiographic studies >Electroencephalography >Electrocardiography >Urinalysis >Sequential multiple analyzer 12-test serum profile >Thyroid function tests >Folate level >Venereal Disease Research Laboratories (VDRL), human immunodeficiency virus tests >Serum creatinine assay >Electrolyte assessment >Vitamin B12 level >Liver function tests >Vision and hearing evaluation >Neuroimaging (when diagnostic issues are not clear)

Problems that May Effect People with Dementia and Their Families Table 17-6 Risks Outside the Home

>Competence, judgment, and risks at work >Driving, road sense >Getting lost

Alzheimer's disease (AD) pg. 379

>Constitutes 50-60% of all dementias >rate increases with age, after 65 the number of people doubles for every 5-yeat interval >indiscriminate (men, women, various ethnicities, rich and poor, varying degrees of intelligence) >Exact cause is unknown >brain atrophy with enlargement of cortical sulci and cerebral ventricles >amyloid plaques (cause or effect of disease??) >family history may play a role (early onset ages 30-60 is inherited 3 genes have been identified) >a susceptibility gene found in late onset >noninherited risk factors age, Down syndrome, and head injury >increasing evidence that physical, mental and social activities may serve as protective factors. and risk factors related to cardiovascular disease may increase risk of AD -many experts believe that primary prevention should focus on certain risk factors, including vascular disease, hypertension, smoking, type 2 diabetes, and hyperlipidemia

Causes of Delirium (Metabolic Disorders) Box 17-1

>Dehydration >Hypoxia (pulmonary disease, heart disease, and anemia) >Hypoglycemia >Sodium, potassium, calcium, magnesium, and acid-base imbalances >Hepatic encephalopathy or uremic encephalopathy >Thiamine (vitamin B1) deficiency (Wernicke encephalopathy) >Endocrien disorders (e.g. thyroid or parathyroid) >Hypothermia or hyperthermia >Diabetic acidosis

Problems that May Effect People with Dementia and Their Families Table 17-6 Emotional Reactions

>Depression >Anxiety >Frustration or anger >Embarrassment and withdrawal

Causes of Delirium (Drugs) Box 17-1

>Digitalis, steroids,lithium, levodopa, anticholinergics, benzodiaxepines, central nervous system depressants, tricyclic antidepressants >Central anticholinergic syndrome due to use of multiple drugs with anticholinergic side effects

Problems that May Effect People with Dementia and Their Families Table 17-6 Burden on Family

>Disruption of social life >Distress, guilt, rejection >Family discord

Problems that May Effect People with Dementia and Their Families Table 17-6 Uncontrolled Emotion

>Distress >Anger or aggression >Demands for attention

Problems that May Effect People with Dementia and Their Families Table 17-6 Need for Physical Help

>Dressing >Washing, bathing >Toileting >Eating >Performing Housework >Maintaining Mobility

Problems that May Effect People with Dementia and Their Families Table 17-6 Poor Communication

>Dysphasia

Problems that May Effect People with Dementia and Their Families Table 17-6 Risk in the Home

>Falls >Fire form cigarettes, cooking, heating >Flooding >Admission of strangers to home >Wandering out

Problems that May Effect People with Dementia and Their Families Table 17-6 Caregiver Role Strain

>Family members will have the opportunity to express "unacceptable" feelings in a supportive environment. >Family members will have access to professional counseling. >Family members will name two organizations within their geographical area that can offer emotional support and help with legal and financial burdens. >Family members will participate in ill member's plan of care, with encouragement from staff. >Family members will state that they have outside help that allows them to take personal time for themselves each week or month

Stage 4 (Late) End Stage; Alzheimer's Disease table 17-5

>Family recognition disappears; does not recognize self in mirror >Nonambulatory; shows little purposeful activity; often mute; may scream spontaneously >Forgets how to eat, swallow, chew; commonly loses weight; emaciation common >Has problems associated with immobility (e.g. pneumonia, pressure ulcers, contractures) >Incontinence common; seizures may develop >Most certainly institutionalized at this point >Return of primitive (infantile) reflexes

Problems that May Effect People with Dementia and Their Families Table 17-6 Memory Impairment

>Forgets appointments, visits, etc. >Forgets to change cloths, wash, go to the toilet >Forgets to eat, take medications >Loses things

Problems that May Effect People with Dementia and Their Families Table 17-6 decision Making

>Indecisive >Easily influenced >Refuses help >Makes unwise decisions

Abilities in Stage 2 Alzheimer's Disease Box 17-4

>Initiate familiar activity if supplies are available and within reach >Perform steps of self-care with verbal and tactile cues >Tell stories form past >Read words slowly out loud >Follow simple instructions >Speak in short sentences or phrases; able to make needs known >Sort, stack objects, count >Ambulate if no physical disability is present >Feel and name objects

Problems that May Effect People with Dementia and Their Families Table 17-6 Apathy

>Little conversation >Lack of interest >Poor self-care

Problems that May Effect People with Dementia and Their Families Table 17-6 Impaired Environmental Interpretation: Chronic Confusion

>Person will acknowledge the reality of an object or a sound that was misinterpreted (illusion), after it is pointed out. >Person will state that he or she feels safe after experiencing delusions of illusions. >Person will remain nonaggressive when experiencing paranoid ideation.

Problems that May Effect People with Dementia and Their Families Table 17-6 Communication

>Person will communicate needs. >Person will state needs in alternative modes when he or she is aphasic (e.g. will signal correct word on hearing it or will refer to picture or label) >Person will wear prescribed glasses or hearing aid each day.

Problems that May Effect People with Dementia and Their Families Table 17-6 Agitation Level

>Person will have rest periods if pacing and restless >Person will cooperate with caregiving activities >Person will experience minimal frustrating experiences. >Person will express frustrations in an appropriate manner

Problems that May Effect People with Dementia and Their Families Table 17-6 Self-Care Needs

>Person will participate in self-care at optimal level. >Person will be able to follow step-by-step instructions for dressing, bathing, and grooming. >Person will put on own clothes appropriately, with aid of fastening tape (Velcro) and nursing supervision. >Person's skin will remain intact and free from signs of pressure.

Nursing Outcomes Related to Dementia Box 17-5 Injury

>Person will remain sage in the hospital or at home. >With the aid of an identification bracelet and neighborhood or hospital alert, the person will be returned within 1 hour of wandering >With the aid of interventions, person will remain burn free. >With the aid of guidance and environmental manipulation, person will not hurt himself or herself if a fall occurs. >Person will ingest only correct doses of prescribed medications and appropriate food and fluids.

Causes of Delirium (Psychosocial Stressors) Box 17-1

>Relocation or other sudden changes >Sensory deprivation or overload >Sleep deprivation >immobilization >pain

Problems that May Effect People with Dementia and Their Families Table 17-6 Repetitiveness

>Repetition of questions or stories >Repetition of actions

Problems that May Effect People with Dementia and Their Families Table 17-6 Uncontrolled Behavior

>Restlessness day or night >Vulgar table or toilet habits >Undressing >Sexual disinhibition >Shoplifting

Stage 3 (Moderate to Severe) Ambulatory dementia; Alzheimer's Disease table 17-5

>Shows ADL losses (in order): willingness and ability to bathe, grooming, choosing clothing, dressing, gait and mobility, toileting, communication, reading, and writing skills >Shows loss of reasoning ability, safety planning, and verbal communication >Frustration common; becomes more withdrawn and self-absorbed >Depression resolves as awareness of losses diminishes >Has difficulty communicating; shows increasing loss of language skills >Shows evidence of reduced stress threshold; institutional care usually needed

Stage 2 (Moderate) Confusion; Alzheimer's Disease table 17-5

>Shows progressive memory loss; short-term memory impaired; memory difficulties interfere with all abilities >Withdrawn form social activities >Shows declines in instrumental activities of daily living, such as money management, legal affairs, transportation, cooking, housekeeping >Denial common; fears "losing his or her mind" >Depression increasingly common; frightened because aware of deficits; covers up for memory loss through confabulation >Problems intensified when stressed, fatigued, out of own environment, ill >Commonly needs day care or in-home assistance

Stage 1 (Mild) Forgetfulness; Alzheimer's Disease table 17-5

>Shows short-term memory losses; loses things, forgets >Memory aids compensate; lists, routines, organization >Aware of the problem; concerned about lost abilities >Depression common-worsens symptoms >Not diagnosable at this time

Normal Aging Vs Dementia Memory Deficit Table 17-4 Degree of change:

>Slowing is part of normal aging, but with dementia it is more severe and increasing >Normal aging results in cautiousness but with dementia it is variable >Reduced ability to solve new problems is part of normal aging but is more severe and increasing with dementia >Mildly impaired memory is normal aging but in dementia it is more severe and progressive. >Normal aging causes a mild decline in fluid intelligence but with dementia it is more severe and increasing intellectual impairment

Problems that May Effect People with Dementia and Their Families Table 17-6 Mistaken Beliefs

>Still at work >Parents or spouse still alive >Hallucinations

Problems that May Effect People with Dementia and Their Families Table 17-6 Other Reactions

>Suspiciousness >Hoarding and hiding

Causes of Delirium (Infections) Box 17-1

>Systemic: pneumonia, typhoid fever, malaria, urinary tract infection, and septicemia. >Intracarnial : meningitis and encephalitis

Problems that May Effect People with Dementia and Their Families Table 17-6 Disorientation

>Time: mixes night and day, mixes days of appointments, wears summer clothes in winter, forgets age >Place: loses way around house >Person: has difficulty recognizing visitors, family, spouse

Problems that May Effect People with Dementia and Their Families Table 17-6 Incontinence

>Urine >Feces >Urination or defecation in the wrong place

delirium pg. 370

>characterized by a disturbance of consciousness and a change in cognition that develop over a short period of time >considered a priority problem, and immediate attention should be given to prevent irreversible and serious damage >common in hospitalized patients (AIDs, cancer and elderly highly affected) >always secondary to another physiological condition and is a transient disorder. >If underlying cause is corrected, complete recovery should occur >major causes are; nervous system disease, systemic disease (cardiac failure) and either intoxication or withdrawal from a chemical substance. >clinicians should assume that any drug taken could result in delirium >Risk factors: existing cognitive impairment, low functional autonomy, polypharmacy (especially benzodiazepines, narcotic analgesics, and anticholinergics) and clinical severity of the primary illness

illusions pg. 373

>errors in perception of sensory stimuli. >bedclothes are rats or cord as a snake >stimulus is a present object that is misinterpreted and becomes an object of fear > can be explained and clarified for the individual (unlike delusions and hallucinations)

hallucinations pg. 373

>false sensory stimuli >visual ate common in delirium and tactile may also be present >giant spiders climbing on the walls, or bugs crawling on them >auditory occur more often in other psychiatric disorders such as schizophrenia

primary dementia pg. 379

>irreversible, progressive and not secondary to any other disorder. >Alzheimer's and vascular dementias

aphasia pg. 381

>loss of language ability >progresses with disease >Initially difficulty finding the right word >then reduced to only a few words >Finally reduced to babbling or mutism

apraxia pg.381

>loss of purposeful movement in the absence of motor or sensory impairment >unable to perform once-familiar tasks >example: inability to walk or dress properly(may put arms in pants)

agnosia pg. 381

>loss of sensory ability to recognize objects > may lose the ability to recognize familiar sounds (auditory), such as the ring of the telephone, a car horn, or the doorbell. > may extend to inability to recognize familiar objects (visual or tactile) such as a glass, magazine, pencil, or toothbrush. >Eventually people are unable to recognize loved ones or even parts of their own bodies.

dementia pg. 378

>progressive deterioration of cognitive functioning and global impairment of intellect with no change in consciousness. >manifested as difficulty with memory, thinking, and comprehension. >majority are irreversible but some cases are due to reversible illness >clinical term used to describe a decline in cognitive functioning that interferes with daily living.

perseveration pg. 381

>repetition of phrases or behavior >intensified during stress

secondary dementia pg. 379

>results from some other pathological disease >AID's dementia complex, viral encephalitis, pernicious anemia, folic acid deficiency and hypothyroidism >Korsakoff's syndrome (caused by thiamine (B1) deficiency which is associated with heavy prolonged alcohol ingestion. Marked by peripheral neuropathy, cerebellar ataxia, confabulation, and myopathy

confabulation pg. 380

>the creation of stories or answers in place of actual memories to maintain self-esteem >Not the same as lying. When people are lying they are aware they are making it up >unconscious attempt to maintain self-esteem

Diagnostic Criteria for Delirium Fig 17-1

A. Disturbance of consciousness (i.e. reduced clarity of awareness of the environment with reduced ability to focus, sustain or shift attention). B. A change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. Due to: 1. A general medical condition. Or 2. Substance-induced (intoxication or withdrawal) Or 3. Multiple etiologies (both 1 and 2 above) Or 4. Not known (not otherwise specified)

Diagnostic Criteria for Amnestic Disorder Fig 17-1

A. The development of memory impairment as manifested by impairment in the ability to learn new information or the ability to recall previously learned information. B. The memory disturbance causes significant impairment in social or occupational functioning and represents a significant decline from a previous level of functioning. C. The memory disturbance does not occur exclusively during the course of a delirium or a dementia.

Diagnostic Criteria for Dementia Fig 17-1

A. The development of multiple cognitive deficits manifested by both: 1. Memory impairment (impaired ability to learn new information or to recall previously learned information). 2. One (or more) of the following cognitive disturbances: a. aphasia (language disturbance) b. apraxia (impired ability to carry out motor activities despite intact motor function) c. agnosia (failure to recognize or identify objects despite intact sensory function). d. disturbance in executive functioning (i.e. planning, organizing, sequencing, abstracting). B.The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.

Atypical Antipsychotics Aripiprazole (Abilify) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

ACTION: Blockage of serotonin and dopamine receptors INDICATIONS: Used with extremecaution for paranoid thinking, hallucinations, and agitation. Questionable efficacy in clinical trials. SIDE EFFECTS: Many; see chapters 3 and 15. Weight gain, increased serum glucose, and hyperlipidemia WARNINGS: Lower dos used in older adults. Nighttime dose is preferred. FDA alert for increased risk of CVA and death in dementia patients issued in 2005.

Selective Serotonin Reuptake Inhibitors Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft)

ACTION: Blocks the reuptake of serotonin, thereby making more available and improving mood INDICATIONS: Useful with depression, irritability, sleep disturbances, and anxiety SIDE EFFECTS: Agitation, insomnia, headache, nausea and vomiting, sexual dysfunction, and hyponatremia WARNINGS: Discontinuation syndrome_dizziness, insomnia, nervousness, irritability, nausea, and agitation-may occur with abrupt withdrawal (depending on half-life) Taper slowly.

Antianxiety Agents Loraxepam (Ativan) Oxaxepam (Serax)

ACTION: Facilitates the action of the inhibitory neurotransmitter GABA INDICATIONS: anxiety, restlessness, verbally disruptive behavior, and resistance SIDE EFFECTS: Drowsiness, dizziness headaches. Restlessness, insomnia, and increased anxiety possible WARNINGS: Use cautiously due to risk for further memory impairment, sedation and falls

N-Methyl-D-Aspartate (NMDA) Antagonist Memantine (Namenda)

ACTION: Normalizes levels of glutamate, which in excessive quantities contributes to neurodegeneration INDICATIONS: Treatment of moderate to severe Alzheimer's disease. No evidence that it modifies underlying disease. SIDE EFFECTS: Dizziness, agitation, headache, constipation, and confusion WARNINGS: Clearance is reduced with renal impairment. Use cautiously with moderate renal impairment. Do not use with severe renal impairment.

Cholinesterase Inhibitors Tacrine (Cognex) Donepazil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne)

ACTION: Prevent the breakdown of acetylcholamine and thereby increase its availability at cholinergic synapses INDICATIONS: Modestly improves cognition, behavior, function. Slows disease progression. SIDE EFFECTS: Nausea, vomiting, diarrhea, insomnia, fatigue, muscle cramps, incontinence, bradycardia, and syncope WARNINGS: ______no longer used extensively, owing to hepatotoxicity. ______is better tolerated; dosage is only once a day and is preferred. ________available as a once-daily patch.

Anticonvulsants Carbamazepine (Tegretol) Divalproex (Depakote)

ACTION: reduces the excitability of neurotransmission INDICATIONS: Agitated and aggressive behavior and emotional lability SIDE EFFECTS: Ataxia, sedation, confusion, and (rarely) bone marrow suppression WARNINGS: Monitor the complete blood count and liver-associated enzymes.

Read Considering Culture pg. 378

Caregiver Burden in Dementia

Read Case Study and Nursing Plan 17-1 pg. 395-399

Cognitive Impairment

Read Box 17-2 pg. 377

NIC Interventions for Delirium Management

Read Box 17-6 pg. 388

NIC Interventions for Dementia Management

Normal Aging Vs Dementia Memory Deficit Table 17-4 Rate of Change

Normal Aging: Slow change over many years Dementia: More rapid though gradual changes

Normal Aging Vs Dementia Memory Deficit Table 17-4 Extent of Damage

Normal Aging: difficulty in word finding, but no dysphasia, dyspraxia, agnosia Dementia: Dysphasia, dyspraxia, agnosia often found

Causes of Delirium (Neurological Diseases) Box 17-1

Siezures Head trauma Hypertensive Encephalopathy

Read Evidence-Based Practice pg 372-373

Strategies for Managing Delirium in Hospitalized Older Patients

pseudodementia pg. 381

a disorder that mimics dementia

sundowning pg. 373 aka sundown syndrome

symptoms and problem behaviors become more pronounced in the evening, may occur in both delirium and dementia

hyperorality pg. 384

the need to taste, chew and put everything in one's mouth