Chpt 31- Mental health disorders for OA

Social interactions

AD interferes with a person's ability to interact socially as much as it disrupts intellectual functioning. The patient's whole social network is affected by AD and the primary caregiver of a person with AD (usually the partner or offspring in a community setting) is often considered a copatient. It is important to assess the family caregiver's ability to use supportive mechanisms to maintain his or her own integrity throughout the disease process. If the patient still resides in the community, a home visit will prove useful because it provides information about the patient in the natural environment. From this assessment, the situational and psychosocial stressors that affect the family and patient can be identified, so interventions to strengthen coping strategies, including the ability to seek help from appropriate community resources, can be developed.

Alzheimer's

AD is a degenerative, progressive, neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death. Gradually, the patient's ability to carry out ADLs declines, although physical status often remains intact until late in the disease. Although primarily a disorder of older adults, AD has been diagnosed in patients as young as age 35 years. Two subtypes have been identified: early-onset AD (age 65 years and younger) and late-onset AD (age older than 65 years). Late-onset AD is much more common than early-onset AD, but early-onset AD has a more rapid progression. AD is also routinely conceptualized in terms of three stages: mild, moderate, and severe. The diagnosis of AD is made on clinical grounds, but verification is only confirmed during autopsy. The essential feature of AD is cognitive decline from a previous level of functioning in one or more cognitive domains (attention, executive function, learning and memory, language, perceptual-motor or social cognition). These deficits interfere with independence in ADLs. Typical deficits include aphasia (i.e., alterations in language ability), apraxia (i.e., impaired ability to execute motor activities despite intact motor functioning), agnosia (i.e., failure to recognize or identify objects despite intact sensory function), or a disturbance of executive functioning (i.e., ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior). Mild neurocognitive impairment (MCI) is diagnosed if a modest cognitive decline from a previous level of function is found in one or more of the cognitive domains, but the cognitive deficits do not interfere with independence in daily activities MCI is thought to be related to multiple causes and some, but not all, progress to AD. MCI is categorized according to type of memory loss. In amnestic MCI, an individual may start to forget important information such as appointments, conversations, or events. In nonamnestic MCI, impairment in visual perception, the ability to make sound decisions, or the capacity to judge the time or sequence of steps needed to complete a complex task occurs

Recovery (Delirium)

Although delirium may be recognized and diagnosed in any health care setting, appropriate intervention usually requires that the patient be admitted to an acute care setting for rigorous assessment and rapid treatment. Priority in care is identifying the underlying cause of the delirium. Interdisciplinary management of delirium includes two primary aspects: (1) elimination or correction of the underlying cause and (2) symptomatic and supportive measures (e.g., adequate rest, comfort, maintenance of fluid and electrolyte balance, and protection from injury). Risk Factors for Delirium Advanced age Pre-existing dementia Functional dependence Endocrine and metabolic disorders Bone fracture Infection (pneumonia, urinary tract) Medications (anticholinergic side effects) Changes in vital signs (including hypotension and hyper- or hypothermia) Electrolyte or metabolic imbalance (dehydration, renal failure, hyponatremia) Admission to a long-term care institution Postcardiotomy AIDS Pain Acute or chronic stress Substance use and alcohol withdrawal Safety Issues If possible, the use of all suspected medications should be stopped and vital signs should be monitored at least every 2 hours. Close observation of the patient with particular regard to changes in vital signs, behavior, and mental status is required. Patients are monitored until the delirium subsides or until discharge. If the delirium still exists at discharge, it is critical that referrals for postdischarge follow-up assessment and care be implemented.

Medication with anticholinergic effect

Amitriptyline Captopril (Capoten) Codeine Cimetidine (Tagamet) Citalopram (Celexa) Digoxin (Lanoxin) Diphenhydramine Dipyridamole (Trental) Donepezil (Aricept) Escitalopram (Lexapro) Furosemide (Lasix) Fluoxetine (Prozac) Isosorbide (Ismotic) Mirtazapine (Remeron) Nifedipine (Procardia) Oxybutynin ER Paroxetine (Paxil) Phenytoin (Dilantin) Prednisolone Ranitidine (Zantac) Theophylline Triamterene and hydrochlorothiazide Tolterodine (Detrol LA) Warfarin (Coumadin)

Behavioral

Apathy and Withdrawal. Apathy, the inability or unwillingness to become involved with one's environment, is common in AD, especially in the moderate to late stages. Apathy leads to withdrawal from the environment and a gradual loss of empathy for others. This lack of empathy is very difficult for families and friends to understand. Restlessness, Agitation, and Aggression. Restlessness, agitation, and aggression are relatively common in the moderate to late stages of AD. Restlessness should be further evaluated to determine its underlying cause. If the restlessness occurs during medication change or adjustment, side effects should be suspected. Aberrant Motor Behavior. Symptoms such as fidgeting, picking at clothing, wringing hands, loud vocalizations, and wandering may all be signs of such underlying conditions as dehydration, medication reaction, pain, or infection (suggesting delirium). One of the most difficult behaviors for which to determine an underlying cause is hypervocalization, a term comprising the screams, curses, moans, groans, and verbal repetitiveness that are common in the later stages of AD in cognitively impaired older adults, often occurring during a hospitalization or nursing home placement. In the assessment of these hypervocalizations, it is important to identify when the behavior is occurring; antecedents of the behavior; and any related events, such as a family member leaving or a change in stimulation. Disinhibition. One of the most frustrating symptoms of AD is disinhibition, acting on thoughts and feelings without exercising appropriate social judgment. In AD, the patient may decide that he or she is more comfortable naked than with clothes. Or the patient may not be able to find his or her clothes and may walk into a room of people without any clothes on. This behavior is extremely disconcerting to family members and can also lead to nursing home placement. Hypersexuality. A closely related symptom is hypersexuality, which is inappropriate and socially unacceptable sexual behavior. The patient begins talking and behaving in ways that are uncharacteristic of premorbid behavior. This behavior is very difficult for family members and nursing home staff. Stress and Coping Skills. Patients with AD seem extremely sensitive to stressful situations and often do not have the coping abilities to deal with such situations. A careful assessment of the triggers that precede stressful situations will help in understanding a provoking event.

Medications

As the underlying medical problem is treated, the person may be given medication to treat the symptoms associated with delirium, such as agitation, inattention, combativeness, insomnia, and psychosis. Dosages are usually kept very low, especially with older adults and the medication is selected in light of the potential side effects (particularly anticholinergic effects, hypotension, and respiratory suppression). Antipyschotics are often used for a targeted group of patients who experience hallucinations or delusions associated with delirium. Recent research suggests that supportive measures and treatment of precipitating factors are more effective than antipsychotics. Benzodiazepines are also used when the delirium is related to alcohol withdrawal. In some patients, benzodiazepines may further impair cognition because of the sedation. Patients should be monitored for sedation, hypotension, or extrapyramidal symptoms. Although mental status often fluctuates during delirium, it may also be influenced by these medications, so any changes or worsening of mental status after administration of the medication should be reported immediately to the prescriber. Some side effects may also be confused with the symptoms of delirium. For example, akathisia, a side effect of antipsychotics, may appear as agitation or restlessness. Medications for treating symptoms related to delirium should be discontinued as soon as possible.

Differentiation between delirium and dementia

Characteristics (Delirium Dementia) Onset Sudden Insidious 24-h course Fluctuating Stable Consciousness Reduced Clear Attention Globally disoriented Usually normal Cognition Globally disoriented Globally impaired Hallucinations Visual auditory Possible Orientation Usually impaired Often impaired Psychomotor activity Increased, reduced, or shifting Often normal Speech Often incoherent; slow or rapid Often normal Involuntary movement Often asterixis or coarse tremor Rare Physical illness or drug toxicity One or both Rare

Medications

Cholinesterase inhibitors are indicated for the treatment of AD. These drugs may help to delay or prevent symptoms from becoming worse. Cholinesterase inhibitors are oral medications usually taken once or twice a day. The earlier in the disease process these medications are initiated, the more likely they will delay cognitive decline. Although there are no special monitors for the cholinesterase inhibitors, the prolonged concurrent use of nonsteroidal anti-inflammatory drugs (NSAIDs) with them can increase the risk of stomach ulcers. N-Methyl-D-Aspartic Acid Antagonists. In AD, it is hypothesized that the chronic release of glutamate leads to neuronal degeneration. Memantine (Namenda XR) is an N-methyl-d-aspartic acid (NMDA) receptor antagonist that has been shown to improve cognition and ADLs in patients with moderate to severe symptoms of AD. Memantine and Donepezil Combination. Patients stabilized on daily donepezil may be prescribed Namzaric, a combination of memantine and donepezil in one capsule. This medication is formulated in various strengths of memantine (7, 14, 21, and 28 mg) combined with 10-mg donepezil. Other Medications. Even though antipsychotics are not approved for the use dementia-related psychosis and have a boxed warning for this population, off-label use of antispsychotics for psychosis is common. The evidence for the use of antidepressants for treating symptoms of depression in individuals with dementia is inconclusive, but there is limited research support for their use in reducing agitation. Benzodiazepines should be used with caution and only on a short-term basis to treat anxiety in older adults. Anticholinergic medications should be avoided in patients with AD if at all possible.

Introduction

Cognition is based on a system of interrelated abilities, such as perception, reasoning, judgment, intuition, and memory that allow one to be aware of oneself and one's surroundings. Impairments in these abilities can result in a failure of the afflicted person to recognize that he or she is ill and in need of treatment. Memory, a facet of cognition, refers to the ability to recall or reproduce what has been learned or experienced. It is more than simple storage and retrieval; it is a complex cognitive mental function that includes most areas of the brain, especially the hippocampus, which is believed to be essential to the transfer of some memories from short- to long-term storage. Defects of memory are an essential feature of many cognitive disorders, particularly dementia.

Introduction

Delirium is a disorder of acute cognitive impairment that is caused by a medical condition (e.g., infection), substance abuse, or multiple etiologies. Dementia is characterized by chronic cognitive impairments and is differentiated by underlying cause, not by symptom patterns. Dementia can be further classified as cortical or subcortical to denote the location of the underlying pathology. Cortical dementia results from a disease process that globally afflicts the cortex. Subcortical dementia is caused by dysfunction or deterioration of deep gray- or white-matter structures inside the brain and brain stem. Symptoms of subcortical dementia may be more localized and tend to disrupt arousal, attention, and motivation, but they can produce a variety of clinical behavioral manifestations. In this chapter, one type of cortical dementia, Alzheimer disease (AD), is highlighted because it is the most prevalent form of dementia.

Delirium

Delirium is a disturbance in consciousness and a change in cognition that develops over a short time. It is usually reversible if the underlying cause is identified and treated quickly. It is a serious disorder and should always be treated as a medical emergency. EMERGENCY CARE ALERT ! Individuals with delirium are in a state of confusion and disorientation that develops during a period of a few hours or days. If delirium is not treated in a timely manner, irreversible neurologic damage can occur. Delirium is a common complication in patients admitted to intensive care units and inpatient psychiatric units Impaired consciousness is the key diagnostic criterion for delirium. The patient becomes less aware of his or her environment and loses the ability to focus, sustain, and shift attention. Cognitive changes include problems with memory, orientation, and language. The patient may not know where he or she is, may not recognize familiar objects, or may be unable to carry on a conversation. This problem developed during a short period (compared with dementia, which develops gradually. Delirium is different than dementia, although the presenting symptoms are often similar. Impaired alertness, apathy, anxiety, disorientation, and hallucinations commonly occur NCLEXNOTE Delirium and dementia have similar presentations. Because delirium can be life threatening, identifying the potential underlying cause for the symptoms is a priority. Although delirium may occur in any age group, it is most common among older adults. In this age group, delirium is often mistaken for dementia, which in turn leads to inappropriate treatment. Patients with delirium have a reduced ability to focus, difficulty in sustaining or shifting attention, changes in cognition, or perceptual disturbances

Epidemiology and risk

Dementia appears to affect all groups, but studies in the United States reveal a higher incidence in African Americans and Hispanics than in whites. Currently, AD is the fifth leading cause of death among older adults in the United States General Risk Factors AD can run in families. Compared with the general population, first-degree biologic relatives of individuals with early-onset AD are more likely to experience the disorder. Studies show that those with fewer years of education or those who have had a prior head injury are at higher risk of developing Alzheimer disease Down Syndrome People with Down syndrome are at higher risk of developing AD than others, most likely because of the additional copy of chromosome 21. The amyloid precursor protein (APP) is a gene found on this chromosome that is involved in the formation of neurons and their survival. This gene is cut into smaller fragments (peptides) by enzymes. The extra copy of chromosome 21 increases the amount of beta amyloid fragments in the brain, which in turn increases the possibility of formation of beta-amyloid plaques. By age 40, most people with Down syndrome have increased levels of beta-amyloid plaques and tau tangles in their brain Individuals with metabolic syndrome have a greater risk of developing AD. Metabolic syndrome, a cluster of conditions (hypertension, hyperglycemia, abdominal obesity, and hyperlipidemia) that occur together, increases the risk of heart disease, stroke, and diabetes. Metabolic syndrome is associated with microvascular changes in the brain, which in turn appear to cause mitochondrial dysfunction. Insulin resistance is thought to play a key role in the neuroinflammation and loss of synapses

Nursing interventions

Determining the underlying cause for the delirium is priority. Important interventions include providing a safe and therapeutic environment; maintaining fluid and electrolyte balance and adequate nutrition and preventing aspiration and decubitus ulcers, which are common complications. Other interventions relate to individual symptoms and underlying causes. Safety Interventions Behaviors exhibited by the person with delirium, such as hallucinations, delusions, illusions, aggression, or agitation (restlessness or excitability), may pose safety problems. Because individuals with delirium are more likely to fall or injure themselves during a confused state, special precautions and safety measures should be considered. The patient must be protected from physical harm by using low beds, guardrails, and careful supervision. Delirium management and fall prevention may be implemented for any patient at risk for falls. Complementary and Alternative Medication Interventions There is strong evidence that complementary and alternative medicine interventions are effective in reducing agitation and delirium in older adults. Aromatherapy, massage, acupuncture, and therapeutic touch have been used successfully in reducing agitation and aggressive behavior

Evaluate

Evaluation and Treatment Outcomes The objectives of nursing interventions are to help the patient with AD remain as independent as possible and to function at the highest cognitive, physical, emotional, spiritual, and social levels. The maximum level of functional ability can be promoted when nursing care is related to and based on the remaining abilities of the patient. Continuum of Care Community Care It is estimated that more than 60% to 70% of older adults with AD live at home, with 83% of home care provided by family and friends. Unpaid caregivers provide 233.9 billion economic worth. Use of community-based services (e.g., home health aides, home-delivered meals, adult day care centers, respite care, caregiver support groups) often extends the amount of time an individual with AD or a related disorder can safely remain in the home. Inpatient-Focused Care Comprehensive admission assessment followed by the development of an individualized (and constantly updated) care plan that involves the patient, significant others, and diverse health care professionals is the foundation of an effective and efficient postdischarge plan. Attention to all aspects of this process is necessary to ensure that the goal of continuity of care is achieved. The hospital-based nurse may initiate family education and counseling as part of discharge planning. Nursing Home Care As the AD progresses, many patients are placed in a nursing home for care. Nursing care in a nursing home is usually delivered by nurses' aides, who need support and direction. Interestingly, people with AD require complex nursing care, but the skill level of people caring for these individuals often is minimal. Education and support of the direct caregiver is the focus of most nursing homes

Evaluation

Evaluation and Treatment Outcomes The primary treatment goal is prevention or resolution of the delirious episode with return to previous cognitive status. Outcome measures include: Correction of the underlying physiologic alteration Resolution of confusion Family member verbalization of understanding of confusion Prevention of injury Resolution of confusion is the primary goal; however, the nursing care provided makes important contributions to all four of these outcomes. The end result of delirium may be full recovery, incomplete recovery, incomplete recovery with some residual cognitive impairment, or a downward course leading to death. Continuum of Care Patients with delirium may present in a number of treatment settings (e.g., home, nursing home, ambulatory care, day treatment, outpatient setting, hospital). Patients usually are admitted to an acute care setting for rapid evaluation and treatment of the underlying etiology.

Family response

Families are the first to be aware of the cognitive problem, often before the patient, who can be unaware of the extent of memory impairment. When finally confirmed, the actual diagnosis can be devastating to the family. Unlike delirium, a diagnosis of AD means long-term care responsibilities while the essence of a family member diminishes day by day. Most families keep their relative at home as long as possible to maintain contact and to avoid costly nursing home placement. The two symptoms that often result in nursing home placement are incontinence that cannot be managed and behavioral problems, such as wandering and aggression.

Home visits

Home Visits The goal of in-home and community-based long-term care services is to maintain patients in a self-determining environment that provides the most home-like atmosphere possible, allows maximum personal choice for care recipients and caregiver and encourages optimal family caregiving involvement without overwhelming the resources of the family network. All services for patients with AD and their families must be provided within a context of continuity of care, a concept that mandates access to various health and supportive services over an unpredictable and changing clinical course. Community Actions Nurses working with patients with AD are especially knowledgeable about all aspects of the illness and care. These nurses are often involved in local organizations, such as the Alzheimer's Association. Issues of care and safety and reimbursement for services often require professional expertise and influence. Family Interventions Especially in AD, the needs of family members should also be considered. Caring for a family member with dementia takes its toll. Eighty percent of the home care is provided by family caregivers. Two thirds of the caregivers are women, and 34% are over the age of 65 years. Caregivers' health often declines and directly affects their ability to provide care. Caregivers are faced with extreme pressures and often feel isolated, frustrated, and trapped. The potential for patient abuse is significant, especially if agitated and aggressive behaviors are present in the relative.

Substance induced TBI

If dementia results from the persisting effects of a substance (e.g., drugs of abuse, a medication, exposure to toxins), substance-induced neurocognitive disorder is diagnosed. Other causes of dementia (e.g., dementia caused by a general medical condition) must always be considered even in a person with a dependence on or exposure to a substance. For example, head injuries often result from substance use and may be the underlying cause of the neurocognitive changes. Prescription drugs are the most common toxins in older adults. TBI

Mood changes interventions

Managing Depression. Psychotherapeutic nursing interventions for depression that accompanies AD are similar to interventions for any depression. It is important to spend time alone with patients and to personalize their care as a way of communicating the patient's value. Encouraging expression of negative emotions is helpful because patients can talk honestly to a nonjudgmental person about their feelings. Although depressed patients with AD are likely to be too disorganized to attempt suicide, it is wise to remove potentially harmful objects from the environment. Managing Stress and Anxiety. Cognitively impaired patients are particularly vulnerable to anxiety. Patients with AD become unsure of their surroundings or of what is expected of them and then tend to react with fear and distress. They may feel lost, insecure, and left out. Failure to complete a task formerly regarded as simple creates anxiety and agitation. Often, they cannot explain the source of their anxiety. In many cases, lowering the demands, simplifying routines, and reducing the number of choices alleviates the anxiety. Managing Catastrophic Reactions. If a patient reacts catastrophically, remain calm, minimize environmental distractions (quiet the environment), get the patient's attention, and softly assure the patient that he or she is safe. Give information slowly, clearly, and simply, one step at a time. Let the patient know that you understand the fear or other emotional response, such as anger or anxiety. As nursing skills are developed in identifying antecedents to the patient's catastrophic reactions, it becomes possible to avoid situations that provoke such reactions. Patients with AD respond well to structure but poorly to change. Attempts to argue or reason with them will only escalate their dysfunctional responses. Managing Apathy and Withdrawal. As the patient withdraws and becomes more apathetic, it becomes more challenging to engage the patient in meaningful activities and interactions. Providing this level of care requires knowing the premorbid functioning level of the patient. Close contact with family helps provide ideas about meaningful activities.

Psychosocial interventions

Managing Hallucinations. Reassurance and distraction may be helpful for the hallucinating patient. For example, an 89-year-old patient with AD in a residential care facility would get up each night, walk to the nursing station, and whisper to the nurses, "There's a man in my bed who won't let me sleep. You should patrol this place better!" If the hallucination is not too disturbing for the patient, it can often be dismissed calmly with diversion or distraction. Because this patient did not seem too concerned by the man in her bed, the nurse may gently respond by saying, "I'm sorry you have to put up with so much. Just wait here (or come with me) and I'll make sure your room is ready for you." The nurse should then take the patient back to her room and help her into bed. Frightening hallucinations and delusions usually require antipsychotic medications to dampen the patient's emotional reactions, but they can also be dealt with by optimizing perceptual cues (e.g., cover mirrors, turn off the television) and by encouraging patients to stay physically close to their caregivers. For example, one patient complained to her visiting nurse that she was being poisoned by deadly bugs that crawled up and down her arms and legs while she tried to sleep at night. Antipsychotic medication may help this patient sleep at night and she would also likely benefit from reassurance and protection.

Mood change interventions

Managing Restlessness and Wandering. Restlessness and wandering are major concerns for caregivers, especially in the community (home) or long-term care setting. The principal means of dealing with restless patients who wander into other patients' rooms or out of the door is to have an adequate number of staff (or caregivers in the home setting) to provide supervision, as well as electronically controlled exits. Wandering behavior may be interrupted in more cognitively intact patients by distracting them verbally or visually. Patients who are beyond verbal distraction can be distracted by physically joining them on their walk and then interrupting their course of action and gently redirecting them back to the house or facility. Many times, wandering is a result of a patient's inability to find his or her own room or may represent other agenda-seeking behaviors such as trying to find a bathroom. Managing Agitated Behavior. Agitated behavior is likely to occur when patients are pressed to assist in their own care. A calm, unhurried, and undemanding approach is usually most effective. Attempts at reasoning may only aggravate the situation and increase the patient's resistance to care. If unable to determine the source of the patient's anxiety, the patient's restless energy can often be channeled into activities such as walking. Relaxation techniques also can be effective for reducing behavioral problems and anxiety in patients with AD. Managing Aberrant Behavior. When patients are picking in the air or wringing hands, simple distraction may work. Hypervocalizations are another story. Direct care staff tend to avoid these patients, which only makes the vocalizations worse. In reality, these vocalizations may have meaning to the patient. Instead, develop strategies to try to reduce the frequency of vocalizations (Table 31.4). Reducing Disinhibition. Anticipation of disinhibiting behavior is the key to nursing interventions for this problem. Disinhibition can take many forms, from undressing in a public setting to touching someone inappropriately to making cruel but factual statements. This behavior can usually be viewed as normal by itself but abnormal within its social context. Keen behavioral assessment of the patient increases the ability to anticipate the likely socially inappropriate behavior and redirect the patient or change the context of the situation. If the patient starts undressing in the dining room, offering a robe and gently escorting him or her to another part of the room might be all that is needed. If a patient is trying to fondle a staff member, having the staff member leave the immediate area or redirecting the patient may alleviate the situation.

Psychosocial interventions

Memory Enhancement. The sooner patients begin taking AChEIs, the slower the cognitive decline will be. However, pharmacologic agents are only a small part of the intervention picture. The nursing goal is to maintain memory function as long as possible. When caring for a patient with AD, a concerted effort should be made to reinforce short- and long-term memory. For example, reminding patients what they had for breakfast, which activity was just completed, or who their visitors were a few hours ago will reinforce short-term memory. Encouraging patients to tell the stories of their earlier years will help bring long-term memories into focus. In the earlier stages of AD, there is considerable frustration when the patient realizes that he or she has short-term memory loss. In a matter-of-fact manner, help "fill in the blanks" and then redirect to another activity. Pictures of familiar people, places, and activities are also important tools in memory retrieval. Using scents (perfume, shaving lotions, spices, different foods) to stimulate memory retrieval and asking patients to relate their memories are also useful. Formalized reminiscence groups also help patients relive their earlier experiences and support maintenance of long-term memories. Orientation Interventions. To enhance cognitive functioning, attempts should be made to remind patients of the day, time, and location. However, if the patient begins to argue that he or she is really at home or that it is really 1992, the patient need not be confronted by facts. Any confrontation could easily escalate into an argument. Instead, either redirect the patient or focus on the topic at hand. Maintaining Language. Losing the ability to name an object (i.e., agnosia) is frustrating. For example, the patient may describe a flower in terms of color, size, and fragrance but never be able to name the flower. When this happens while interacting with a patient, immediately say the name of the item. This reinforces cognitive functioning and prevents disruption in the interaction. Referral to speech therapists may also be useful if the language impairment impedes communication.

Introduction

Memory is a facet of cognition concerned with retaining and recalling past experiences, whether they occurred in the physical environment or internally as cognitive events. Neurocognitive disorders are characterized by a decline in cognitive function from a previous level of functioning. These disorders are acquired and have not been present since early life. The diagnosis of a neurocognitive disorder is based on deficits in the following cognitive domains: attention (distractibility with multiple stimuli), executive function (planning, decision-making, working memory), learning and memory (recall and recognition), language (expressive, including naming, work finding, fluency, grammatical syntax, and receptive language), perceptual-motor (visual perception, visuoconstructional, perceptual-motor), and social cognition deficits (recognition of emotions, ability to consider another's mental state) The neurocognitive disorders discussed in this chapter include delirium and dementia. Delirium is a disorder of acute cognitive impairment usually caused by a medical condition (e.g., infection), substance abuse, or multiple etiologies. Dementia is characterized by chronic cognitive impairments. Dementia is differentiated from delirium by underlying cause, not by symptom patterns, which are often similar.

Psychosocial

Memory. The most dramatic and consistent cognitive impairment is in memory. Patients with dementia appear mildly forgetful and repetitive in conversation. They misplace objects, miss appointments, and forget what they were just doing. They may lose track of a conversation or television show. Initially, they may complain of memory problems, but rapidly in the course of the illness, insight is lost, and they become unaware of what is lost. Sometimes they may confabulate, making what appears to be an appropriate explanation of why the information or object is missing. Eventually, all aspects of memory are impaired and even long-term memories are affected. During the interview, short-term memory loss is usually readily evident by the patient's inability to recall three or four words given to him or her at the beginning of the assessment. Often, the earliest symptom of AD is the inability to retain new information. Language. Language is also progressively impaired. Individuals with AD may initially have agnosia (difficulty finding a word in a sentence or in naming an object). They may be able to talk around it, but the loss is noticeable. Later, fluent aphasia develops; comprehension diminishes; and, finally, they become mute and unresponsive to directions or information. Visuospatial Impairment. Deficits in visuospatial tasks that require sensory and motor coordination develop early, drawing is abnormal, and the ability to write may change. An inaccurate clock drawing is diagnostic of impairment in this area. Sequencing tasks, such as cooking or other self-care skills, become impaired. The individual becomes unable to complete complex tasks that require calculations, such as balancing a checkbook. Executive Functioning. Judgment, reasoning, and the ability to problem solve or make decisions are also impaired later in the disorder, closer to the time of nursing home placement. It is hypothesized that as the disease progresses, the degeneration of neurons is spread diffusely throughout the neocortex. Psychotic Symptoms. Delusional thought content and hallucinations are common in people with AD. These psychotic symptoms differ from those of schizophrenia.

EBN

Mental Health Nursing Assessment The onset of symptoms is typically signaled by a rapid or acute change in behavior. Assessing the symptoms first requires knowing what is normal for the individual. Caregivers, family members, or significant others should be interviewed because they can often provide valuable information. Family members may be the only resource for accurate information. Physical Health Assessment History should include a description of the onset, duration, range, and intensity of associated symptoms. Recent physical illness, dementia, depression, or other psychiatric illnesses should be identified. A physical examination should be conducted. Vital signs are crucial. Changes in activities of daily living (ADLs), use of sensory aids (eyeglasses and hearing aids), pain, and sleep should be documented. Medication Assessment. Many medications are associated with delirium. Combinations of medications can interact and cause delirium. Cold medications, taken in sufficient quantities may cause confusion, especially in older adults. A substance use history (including alcohol intake and smoking history) should be taken.

Psychosocial

Mental Status. Rapid onset of global cognitive impairment that affects multiple aspects of intellectual functioning is the hallmark of delirium. Mental status evaluation reveals several changes: Fluctuations in level of consciousness with reduced awareness of the environment Difficulty focusing and sustaining or shifting attention Severely impaired memory, especially immediate and recent memory Behavior. Persons with delirium exhibit a wide range of behaviors, complicating the process of making a diagnosis and planning interventions. At times, the individual may be restless or agitated and at other times lethargic and slow to respond. Family Environment. An assessment of living arrangements may provide information about sensory stimulation or social isolation. Assessing family interactions, support for the patient, and family members' ability to understand delirium is also important. The behaviors exhibited by the person experiencing delirium may be frightening or at least confusing for family members. Some family members may actually contribute to the patient's increased agitation. At the same time, however, the family's presence may help to calm and reassure the patient.

Mood

Mood Changes. A depressed mood is common, but major depression and AD appear to be separate disorders. Many people with AD experience one or more depressive episodes with symptoms such as psychomotor retardation, anxiety, feelings of guilt and worthlessness, sadness, frequent crying, insomnia, loss of appetite, weight loss, and suicidal rumination. Depressive symptoms are most prevalent in the early stages of AD, which may be attributed to the patient's awareness of cognitive changes, memory loss, and functional decline. Anxiety. Moderate anxiety is a natural reaction to the fear engendered by gradual deterioration of intellectual function and the realization of impending loss of control over one's life. Failure to complete a task formerly regarded as simple creates a source of anxiety in patient with AD. As patients with AD become unsure of their surroundings and the expectations of others, they frequently react with fear and distress. It is thought that anxious behavior occurs when the patient is pressed to perform beyond his or her ability. Catastrophic Reactions. Catastrophic reactions are overreactions or extreme anxiety reactions to everyday situations. Catastrophic responses occur when environmental stressors are allowed to continue or increase beyond the patient's threshold of stress tolerance. Behaviors indicative of catastrophic reactions typically include verbal or physical aggression, violence, agitated or anxious behavior, emotional outbursts, noisy behavior, compulsive or repetitive behavior, agitated night awakening, and other behaviors in which the patient is cognitively or socially inaccessible. Factors that contribute to catastrophic responses in patients with progressive cognitive decline include fatigue, a change in routine (e.g., faster pace, caregiver), demands beyond the patient's ability, overwhelming sensory stimuli, and physical stressors (e.g., pain, hunger).

Neurocognitive due to prion disease

Neurocognitive disorder due to prion disease comprises a group of spongiform encephalopathies including Creutzfeldt-Jakob disease, a rare, rapidly fatal, brain disorder, and mad cow disease, which is a bovine disorder. A prion is a small infectious particle composed of abnormally folded protein that causes progressive neurodegeneration. Many of the symptoms seen in Creutzfeldt-Jakob disease are similar to those found in AD and other dementias. However, changes in the brain tissue are different in Creutzfeldt-Jakob disease and are best differentiated with surgical biopsy or during autopsy. Common symptoms include fluctuating fever, difficulty swallowing, incontinence, tremors, seizures, and sensitivity to touch and environmental noise. At present, no effective treatment for the disease exists and nothing has been found to slow progression of the illness, although antiviral drug studies are ongoing. Person-to-person transmission of Creutzfeldt-Jakob disease is rare (but possible) and it can be transmitted from people to animals and between animals. Because of the transmissible nature of Creutzfeldt-Jakob disease and because the virus is not easily destroyed, strict criteria for the handling of infected tissues and other contaminated materials have been developed.

Etiology

Neurofibrillary Tangles Neurofibrillary tangles are made of abnormally twisted protein threads found inside the brain cells. The main component of the tangles is tau, a protein that stabilizes the microtubules of transport cells. In AD, tau separates from the microtubules. Loose tau proteins tangle with each other, causing the characteristic neurofibrillary tangles. When microtubules disintegrate, the neuron's transport system collapses, resulting in cell death In patients with AD, neurotransmission is reduced, neurons are lost, and the hippocampal neurons degenerate. Several major neurotransmitters are affected. Cellular loss leads to reduced acetylcholine (ACh) important in cognitive functioning and memory One of the early hypotheses was that cholinergic dysfunction contributed to cognitive deficits associated with aging and AD. This hypothesis was based on evidence that alterations in the cholinergic systems induced cognitive deficits similar to those in AD and aging. When cholinergic functioning was increased, there were beneficial effects. Today we understand that the pathogenesis of AD is much more complicated than a single cause, even though the primary medications for AD target the cholinergic system Genetic Factors Mutations on three genes are identified as causing AD through altering Aβ processing and are transmitted through genetic inheritance—APP, PSEN1, and PSEN2. These mutations explain 5% to 10% of the occurrence of early-onset AD. The majority of early-onset AD cases do not have a clear genetic pattern of inheritance. However, genetic predisposition is estimated to be a factor in 60% to 80% of AD cases, including late-onset AD The APOE gene transports cholesterol in the bloodstream. Three forms of the APOE gene (e2, e3, and e4) are inherited from each parent. The e3 form is the most common and is believed to neither increase or decrease the risk of AD. The e4 is the next most common and is found to increase the risk of developing AD. People with one copy of the e4 form are three times as likely to develop AD compared to those who have the e3 form, and those with two copies of the e4 form have an 8 to 12 times greater risk. The least common APOE gene, e2, is relatively rare and may actually decrease one's risk of AD

Milieu management and socialization

Overstimulating activities (e.g., social outing, family visit) can result in an outburst of delusional accusations or agitation. The nurse should attempt to determine each patient's optimal level of stimulation at various times of the day. It may be that stimulating environments can be tolerated early in the morning but not in the afternoon when the patient is tired. Socialization Activities Overlearned social skills are rarely lost in patients with AD. It is not unusual for patients with dementia to respond appropriately to a handshake or smile well into the disease process. Even patients who are no longer able to communicate coherently will carry on long discussions with people who are willing to listen and respond (to language that does not make sense). The risk for social isolation is strong in patients with AD because of communication difficulties. Reinforcing social remarks and gestures, such as eye contact, smiling, greetings, and farewells, can promote a sense of competency and self-esteem. Pet therapy and "stuffed animal" therapy can also enhance social interaction in cognitively impaired individuals. It is important to remember that patients with AD do not lose their ability to laugh and play and the psychosocial benefits of humor are well known. Activities that elicit pleasant memories from an earlier time in the patient's life (reminiscence) may produce a soothing effect. Eliciting pleasant memories may be enhanced by gentle stimulation of the patient's senses, for example, viewing and discussing photo albums, looking at personal memorabilia, providing a favorite food item, playing a musical instrument, or listening to music the person preferred in younger years. It may be useful to incorporate movement or dance along with a singing exercise. If the patient with AD resists structured exercise, it may be because of a fear of falling or injury or of demonstrating to others that his or her health is failing. Patients with AD often forget how to move or how to coordinate their movements in relation to objects. Therefore, exercise should be light and enjoyable. Encourage the patient to take rest periods at intervals throughout the activity in an effort to minimize stress.

Etiology

Oxidative Stress, Free Radicals, and Mitochondrial Dysfunction It is hypothesized that in AD-affected brains, there is a rapid increase in formation of free radicals (i.e., highly reactive molecules) that can lead to oxidative stress that damages other cellular molecules such as proteins, lipids, and nucleic acid. Recent studies suggest that oxidative stress may result in changes in chromatin (a complex of DNA and proteins), which may lead to dysfunctional gene expression Inflammation Inflammation is now considered as one of many factors that contribute to the development of AD. The hypothesis is that inflammation may damage small blood vessels and brain cells, initiating a cascade of pathologic events related to oxidative damage and dysregulated amyloid metabolism

Physical

Pain and Comfort Management. Nursing care of noncommunicative patients who have AD and who also have pain can be challenging. Because of the difficulty in identifying and monitoring the pain, the patients are often undertreated. However, several measures may be used to assess the efficacy of pharmacologic interventions, such as decreased restlessness and agitation. Small doses of oral morphine solution appear to reduce discomfort during routine nursing procedures. The main side effect of morphine is constipation. Relaxation. Approaching patients in a calm, confident, unhurried manner; maintaining a soothing, quiet environment; avoiding unnecessary noise or chatter around patients and lowering vocal tone and rate when addressing them; maintaining eye contact; and using touch judiciously are likely to promote a sense of security conducive to patient relaxation and comfort. Simple relaxation exercises can be used to reduce stress and should be performed by the patient. Medications. Medications have two goals: restoration or maintenance of cognitive function and treatment of related psychiatric and behavioral disturbances that cause discomfort for the patient, interfere with treatment, or worsen the individual's cognitive status. Doses must be kept extremely low, and patients should be monitored closely for any side effects or worsening of cognitive status. "Start low and go slow" is the principle guiding the administration of psychopharmacologic agents in older patients. Cholinesterase Inhibitors. Acetylcholinesterase inhibitors (AChEIs) are the mainstay of pharmacologic treatment of AD because they inhibit acetylcholinesterase (AChE), an enzyme necessary for the breakdown of acetylcholine. Inhibition of AChE results in an increase in cholinergic activity. Because these medications have been shown to delay the decline in cognitive functioning but generally do not improve cognitive function after it has declined, it is important that this medication be started as soon as the diagnosis is made. The primary side effect of these medications is gastrointestinal distress, including nausea, vomiting, and diarrhea.

Psychosocial interventions

Patients with delirium need frequent interaction and support if they are confused or hallucinating. Patients should be encouraged to express their fears and discomforts that result from frightening or disconcerting psychotic experiences. Adequate lighting, easy-to-read calendars and clocks, a reasonable noise level, and frequent verbal orientation may reduce this frightening experience. If the patient wears eyeglasses or uses a hearing aid, these devices should be used. Including familiar personal possessions in the environment may also help. These interventions have been shown to reduce the need for antipsychotic medication and reduced length of hospitalization. A safe environment is important to protect the patient from injury. A predictable, orienting environment will help to reestablish order to the patient's life. That is, a calendar, clocks, and other items may be provided to help orient the patient to time, place, and person. If the patient is agitated, deescalation techniques should be used. Physical restraint should be avoided. Families can also be encouraged to work with staff to reorient the patient and provide a supportive environment. Families need to understand that important decisions requiring the patient's input should be delayed if at all possible until the patient has recovered. Although patients may be able to participate in decision-making, they may not remember the decision later; therefore, it is important to have several witnesses present.

Psychosocial

Personality changes almost always accompany AD. Researchers have identified two contrasting patterns. One is marked by apathy, lack of spontaneity, and passivity. The other involves growing irritability, sarcasm, self-preoccupation, and intolerance of and lack of concern for others. Cognitive Status. The mental status assessment can be difficult for the patient with AD because cognitive disturbance is the clinical hallmark of AD. However, family members should also be a part of any assessment, especially early in the disease process. There are several screening instruments that can be used in detecting symptoms of dementia. The Mini-Cog is used by clinicians in assessing whether an individual has symptoms of AD. The AD8 Dementia Screening Interview, which is given to a family member, is a brief, sensitive measure that differentiates between those with and without dementia. The AD8 contains eight questions asking the family member to rate any change (yes or no) in memory, problem-solving abilities, orientation, and ADLs. The higher the number of changes, the more likely dementia is present. The nurse should suspect delirium in instances where cognitive deterioration occurs rapidly.

EBN Alzheimers

Physical Health Assessment A review of body systems must be conducted on each patient suspected of having AD. Neurologic function of the patient with AD is usually preserved through the early and middle stages of the disease, although seizures, gait disturbances, and tremors may occur at any time. In the later stages of the disease, neurologic signs, such as flexion contractures and primitive reflexes, are prominent features. Physical Functions. Assessment of physical functions includes ADLs, recent changes in functional abilities, use of sensory aids (e.g., eyeglasses, hearing aids), activity level, and assessment of pain. Eyeglasses and hearing aids may need to be in place before other assessments can be made. At first, limitations may primarily involve instrumental activities of daily living (IADLs), (e.g., shopping, preparing meals, performing other household chores). Later in the disease process, basic physical dysfunctions occur, such as incontinence, ataxia, dysphagia, and contractures. Incontinence can be a major source of stress and a considerable burden to family caregivers. Evaluation of the patient's functional abilities includes bathing, dressing, toileting, feeding, nutritional status, physical mobility, sleep patterns, and pain. Self-Care. Alterations in the central nervous system (CNS) associated with AD impair the patient's ability to collect information from the environment, retrieve memories, retain new information, and give meaning to current situations. Therefore, patients with AD often neglect self-care activities. Periodically, biologic assessment parameters need to be reevaluated because patients with AD may neglect activities such as bathing, eating, or skin care. Sleep-Wake Disturbances. Patients with AD have frequent daytime napping and nighttime periods of wakefulness, with little rapid eye movement (REM) sleep. Lowered levels of REM sleep are associated with restlessness, irritability, and general sleep impairment Activity and Exercise. One of the earliest symptoms of AD is withdrawal from normal activities. Motor activity is affected in the mild stages of AD and can lead to early problems in functional performance. As the disease progresses, the patient may just sit staring at a blank wall. Nutrition. Eating can become a problem for a patient with AD and is associated with rapid cognitive decline. As the disease progresses, patients may lose the ability to feed themselves or recognize that what is being offered is food. Some patients with Alzheimer Disease are bulimic or hyperoral (eating or chewing almost everything possible and sometimes with an insatiable appetite). Other patients with Alzheimer Disease experience anorexia and have no appetite. Pain. Although AD is not usually considered a physically painful disorder, patients often have other comorbid physical diseases that may be painful. In the early stages of AD, the patient can usually respond to verbal questions regarding pain. Later, it may be difficult to assess the comfort level objectively, especially if the patient cannot communicate. Some patients in the end stage of AD become hypersensitive to touch. Subtle behavioral changes, such as lethargy, anxiety, or restlessness, or more obvious physical signs, such as pyrexia, tachypnea, or tachycardia, may be the only indications of actual or impending illness. Observing for changes in patterns of nonverbal communication, such as facial expressions, may help in identifying indicators of pain. Hypervocalizations (disturbed vocalizations), restlessness, and agitation are other possible signs of pain.

Donepezil Galantamine

Prevent Break down ACTH in brain Cholinesterase inhibitor to treat N/V/D Nsaids caution Galantamine- Prevents breakdown of ACTH and modulates nicotinic receptors to release in brain Cholinesterase inhibitors treats N/V/D weight loss Some antidepressants such as paroxetine- retention of excess galantamine in body NSAIDs- caution Memantine- Blocks toxic effects of excess glutamate and regulates activation NMDA antagonist to treat Dizzy, headache, diarrhea, constipation 174 interactions Memantine ER and donepezil- namzaric Blocks toxic effect associated with excess glutamate and prevents breakdown of ACTH NMDA antagonist and cholinesterase inhibitor Headache, N/V/D Combined with NMDA antagonist, anticholinergic meds Rivastigmine- Prevents breakdown of ACTH an butyrylcholine Cholinesterase inhibitor N/V, weight loss and upset stomach NSAID caution

Neurocognitive disorder with lewy bodies

Progressive cognitive decline with visual hallucination, REM sleep disorder, and spontaneous parkinsonism characterizes dementia with Lewy bodies, a major neurocognitive disorder. Cognitive symptoms occur several months before motor symptoms. These symptoms fluctuate and may resemble delirium. These individuals are at high risk for falls because of periods of syncope and transient episodes of consciousness. Orthostatic hypotension and urinary incontinence may occur. The cause is unknown, but evidence implies a genetic component. The pathology involves Lewy bodies found in the cortical location in the brain which are thought to be responsible for the disorder. The estimated prevalence of this dementia ranges from 0.1% to 5% of the general elderly population with men slightly more affected. This onset of disorder is typically in the sixth to ninth decades and is progressive with a 5- to 7-year survival rate. These individuals are more functionally impaired than those with other types of dementia (e.g., AD) and are very sensitive to psychotropic medication, especially antipsychotics.

Frontotemporal neurocognitive disorder

Progressive development of behavioral and personality change and/or language impairment characterizes frontotemporal neurocognitive disorder which has distinct patterns of brain atrophy and distinctive neuropathology. Individuals with this disorder have varying degrees of apathy or disinhibition. They may lose interest in socialization, self-care, and personal responsibilities. Family members report socially inappropriate behaviors, but afflicted individuals show little insight. The cognitive deficits are typically in the areas of planning, organization, and judgments. They are easily distracted

Safety

Safety Interventions In the early stages of the illness, safety may not seem to be a prime issue because the individual is cognitively intact. However, early behaviors suggesting AD are often related to safety, such as the patient getting lost while driving or going the wrong way on the highway. Patients may be prevented from driving even though they can continue to live at home. Safety continues to be an issue in the home when patients engage in unsupervised cooking, cleaning, or household tasks. Day care centers provide a structured yet safe environment for these individuals. Family members should be encouraged to assess continually the abilities of members to live at home safely.

Epidemiology and risk

Statistics concerning prevalence are based primarily on older adults in acute care settings. Estimated prevalence rates range from 10% to 50% of patients. Delirium is particularly common in older postoperative patients. In some groups, such as those with dementia, the prevalence may be higher Pre-existing cognitive impairment is one of the greatest risk factors for delirium Delirium in the older adult is associated with medications, infections, fluid and electrolyte imbalances, metabolic disturbances, hypoxia, or ischemia. The probability of the syndrome developing increases if some predisposing factors, such as advanced age, brain damage, or dementia, are also present. Sensory overload or underload, immobilization, sleep deprivation, and psychosocial stress also contribute to delirium

Physical

Supporting Bowel and Bladder Function. Urinary or bowel incontinence affects many patients with AD. During the middle phases of the disease, incontinence may be caused by the patient's inability to communicate the need to use the toilet or locate a toilet quickly, undress appropriately to use the toilet, recognize the sensation of fullness signaling the need to urinate or defecate, or apathy with lack of motivation to remain continent. For the patient who is incontinent because of an inability to locate the toilet, orientation may be helpful. Signs and active training should help to modify disorientation. Displaying pictures or signs on bathroom doors provides visual cues; words should use appropriate terminology. Sleep Interventions. Sedative-hypnotic agents may be prescribed for a short time for restlessness or insomnia, but they may also cause a paradoxic reaction of agitation and insomnia (especially in older adults). Sleep hygiene interventions are appropriate for patients with AD, although morning and afternoon naps (or rest periods for patients who do not nap) may be the most effective intervention for a patient with altered diurnal rhythms. Activity and Exercise Interventions. Activity and exercise are important nursing interventions for patients with AD. To promote a feeling of success, any activity or exercise plan must be culturally sensitive and adapted to the patient's functional ability and interests. The activity or exercise must be designed to prevent excess stress (both physical and psychological), which means that it must be individualized for each patient with AD based on his or her relative strengths and deficits. Nutritional Interventions. Maintenance of nutrition and hydration are essential nursing interventions. The patient's weight, oral intake, and hydration status should be monitored carefully. Patients with AD should eat well-balanced meals appropriate to their activity level and eating abilities, with special attention given to electrolyte balance and fluid intake. Watch for swallowing difficulties that may put the patient at risk for aspiration and asphyxiation. Swallowing difficulties may result from changes in esophageal motility and decreased secretion of saliva.

Psychosocial interventions

Supporting Visuospatial Functioning. The patient with visuospatial impairments loses the ability to sequence automatic behaviors, such as getting dressed or eating with silverware. For example, patients often put their clothes on backward, inside out, or with undergarments over outer garments. After they are dressed, they become confused as to how they arrived at their current state. If this happens, it may help to place clothes for dressing in a sequence for the patient so the patient can move from one article to the next in the correct sequence. This same technique can be used in other situations, such as eating, bathing, and toileting. Managing Suspicions, Illusions, and Delusions. Delusions often occur when patients are placed in a situation they cannot master cognitively. The principle of nonconfrontation is most important in dealing with formation of suspiciousness and delusion. Efforts should be directed at determining the circumstances that trigger suspicion or delusion formation and creating a means of avoiding these situations. Frequent causes of suspicion occur when changes in daily routine occur. The common accusations that "Someone has entered my room," or "Someone has changed my room" can be managed by asking, "Do you want to see if anything is missing?" Such accusations usually arise when a patient cannot remember what the room looked like or when the room was rearranged or cleaned. Patients with AD often have delusions that a spouse, child, or other significant person is an impostor. If this situation occurs, it is important to assert in a matter-of-fact manner, "This is your wife Barbara" or "I am your daughter Jenny." More vigorous assertions, such as offering various types of proof, tend to increase puzzlement as to why a person would go so far to impersonate the spouse or child. When patients experience illusions, find the source of the illusion and remove it from the environment if possible. For example, if a patient is watching a television program featuring animals and then verbalizes that the animal is in the room, switch the channel and redirect the conversation. Some patients with AD may no longer recognize the reflections in the mirror as themselves and become agitated, thinking that a stranger is staring at them. Potentially misleading or disturbing stimuli, such as mirrors or art work, can be easily covered or removed from the environment.

Psychosocial

Suspiciousness, Delusions, and Illusions. Illusions, or mistaken perceptions, are also common in patients with AD. For example, a woman with AD mistakes her husband for her father. He resembles her father in that he is roughly her father's age when the father was last alive. If an illusion becomes a false fixed belief, it is a delusion. As the disease progresses, delusions develop in 34% to 50% of the people with AD. These characteristic delusions are different from those discussed in the psychotic disorders. Common delusional beliefs include the following: Belief that his or her partner is engaging in marital infidelity Belief that other patients or staff are trying to hurt him or her Belief that staff or family members are impersonators Belief that people are stealing his or her belongings Belief that strangers are living in his or her home Belief that people on television are real and not actors Hallucinations. Visual, rather than auditory, hallucinations are the most common in AD. A frequent complaint is that children, adults, or strange creatures are entering the house or the patient's room. These hallucinations may not seem unusual to the patient. If possible, the content and form of hallucination should be ascertained because this information may suggest a treatable disorder. For example, an auditory hallucination commanding the patient to commit suicide may be caused by a treatable depression, not AD. In some cases, hallucinations may be pleasant, such as children being in the room, or the hallucinations may be frightening and uncomfortable.

Dementia caused by parkinson disease Cause by huntington's

The evidence consistently suggests that low cerebrospinal fluid levels of amyloid-β predict future cognitive decline and dementia in Parkinson disease. Cognitive-enhancing medications have some effect, but there is no convincing evidence that the progression of dementia can be delayed Huntington's disease is a progressive, genetically transmitted autosomal dominant disorder characterized by choreiform movements and mental abnormalities. The onset is usually between the ages of 30 and 50 years, but onset occurs before 5 years of age in the juvenile form or as late as 85 years of age in the late-onset form. The disease affects men and women equally. A person with Huntington's disease usually lives for approximately 15 years after diagnosis. The dementia syndrome of Huntington's disease is characterized by insidious changes in behavior and personality. Typically, the dementia is frontal, which means that the person demonstrates prominent behavioral problems and disruption of attention.

Recovery

The nature and range of services needed by patients and families throughout the illness can vary dramatically at different stages. As with any other patient, the person with AD should be the center of the decision-making process. The plan should include educational and supportive programs individualized for the person's self-identified needs. Ideally, plans should be designed to support self-awareness, self-esteem, maintenance of abilities, and management of behavioral symptoms and health promotion. Treatment efforts currently focus on managing cognitive symptoms, delaying cognitive decline (e.g., memory loss; confusion; and problems with learning, speech, reasoning), treating the noncognitive symptoms (e.g., psychosis, mood symptoms, agitation), and supporting the caregivers to improve the quality of life for both patients and their caregivers. Safety Issues The priority of care changes throughout the course of AD. Initially, the priority is delaying cognitive decline and supporting family members. Later, the priority is protecting the patient from injury because of lack of judgment. Near the end, the physical needs of the patient are the focus of care.

Priority of care

The unique and changing needs of these patients present a challenge for nurses in all settings. Priorities of care vary according to the stage of the disease. Early on, memory impairment and confusion may be present. An individual may begin to feel less connected and engaged in usual activities. As the disease progresses, the patient may have difficulty with their ADLs. Safety concerns may be present, especially if the patient is agitated, aggressive, or prone to wondering. In late stages of AD, the patient may be completely reliant on others in meeting basic health care needs. Mental Health Nursing Interventions Self-Care Interventions Patients should be encouraged to maintain as much self-care as possible. If eyeglasses and hearing aids are needed but not used, patients are more likely to have false perceptual experiences (hallucinations). Oral hygiene can be a problem and requires excellent basic nursing care. Aging and many medications reduce salivary flow, which can lead to a painfully dry and cracking oral mucosa. For patients with xerostomia (dry mouth) hard candy or chewing gum may stimulate salivary flow or modification of the drug regimen may be necessary. Glycerol mouthwash can provide as much relief from xerostomia as artificial saliva. During later stages of AD, bathing can be problematic for the patient and nursing staff. Bath time is a high-risk time for agitation and aggression. The person-centered approach focuses on personalizing care to meet residents' needs, accommodating to residents' preferences, attending to the relationship and interaction with the resident, using effective communication and interpersonal skills, and adapting the physical environment and bathing procedures to decrease stress and discomfort.

vascular neurocognitive disorder

Vascular neurocognitive disorder (also known as vascular dementia) is a decline in thinking skill caused by conditions that block or reduce blood flow to the brain and the second most common type of dementia. Slightly more men than women are affected. Vascular dementia results when a series of small strokes damage or destroy brain tissue. These are commonly referred to as "ministrokes" or transient ischemic attacks (TIAs) and several TIAs may occur before the affected individual becomes aware of the symptoms of vascular dementia. Most often, a blood clot or plaques (fatty deposits) block the vessels that supply blood to the brain, causing a stroke. However, a stroke can also occur when a blood vessel bursts in the brain Symptoms of vascular neurocognitive disorder usually begin more suddenly rather than in AD. Often, the neurologic symptoms associated with a TIA are minimal and may last only a few days, including slight weakness in a limb, dizziness, or slurred speech. Thus, the clinical progression is often described as intermittent and fluctuating or of step-like deterioration, with the patient's cognitive and functional status improving or plateauing for a period of time followed by a rapid decline in function after another series of TIAs. Treatment aims to reduce the primary risk factors for vascular dementia, including hypertension, diabetes mellitus, and additional strokes.

Messages and meanings

"I hurt!" (e.g., from arthritis, fractures, pressure ulcers, degenerative joint disease, cancer) Observe for pain behaviors (e.g., posture, facial expressions, and gait in conjunction with vocalizations). Treat suspected pain judiciously with analgesics and nonpharmacologic measures (e.g., repositioning, careful manipulation of patient during transfers and personal care, warm or cold packs, massage, relaxation). "I'm tired." (e.g., sleep disturbances possibly related to altered sleep-wake cycle with day-night reversal, difficulty falling asleep, frequent night awakenings) Increase daytime activity and exercise to minimize daytime napping and promote nighttime sleep. Promote normal sleep patterns and biorhythms by strengthening natural environmental cues (e.g., provide light exposure during the day; avoid bright lights at night), provide large calendars and clocks. Establish a bedtime routine. Reduce night awakenings: avoid excess fluids, diuretics, caffeine at bedtime, minimize loud noises, consolidate nighttime care activities (e.g., changing, medications, treatments). "I'm lonely." Encourage social interactions between patients and their family, caregivers, and others. Increase time the patient spends in group settings to minimize time in isolation. Provide opportunity to interact with pets. "I need..." (e.g., food, a drink, a blanket, to use the toilet, to be turned or repositioned) Anticipate needs (e.g., assist the patient to toilet soon after breakfast when the gastrocolic reflex is likely). Keep the patient comfort and safety in mind during care (e.g., minimize body exposure to prevent hypothermia). "I'm stressed." (e.g., inability to tolerate sensory overload) Promote rest and quiet time. Minimize "white noise" (e.g., vacuum cleaner) and background noise (e.g., televisions and radios). Avoid harsh lighting and busy, abstract designs. Limit patient's contacts with other agitated people. Reduce behavioral expectations of patient, minimize choices, and promote a stable routine. "I'm bored." (e.g., lack of sensory stimulation) Maximize hearing and visual abilities (e.g., keep external auditory canals free from cerumen plugs, ensure that glasses and hearing aids are worn, provide reading material of large print, soften lighting to reduce glare). Play soft classical music for auditory stimulation. Offer structured diversions (e.g., outdoor activities). "What are you doing to me?" (e.g., personal boundaries are invaded) Avoid startling patients by approaching them from the front. Always speak before touching the patient. Inform patients what you plan to do and why before you do it. Allow for flexibility in patient care. "I don't feel well." (e.g., a urinary or upper respiratory tract infection, metabolic abnormality, fecal impaction) Identify the etiology through patient history, examination, possible tests (e.g., urinalysis, blood work, chest radiography, neurologic testing). Treat underlying causes. "I'm frustrated—I have no control." (e.g., loss of autonomy) When possible, allow patient to make their own decisions. Maximize patient involvement during personal care (e.g., offer the patient a washcloth to assist with bathing). Treat patients with dignity and respect (e.g., dress or change patients in private). "I'm lost." (e.g., memory impairment) Maintain familiar routines. Label the patient's room, bathroom, drawers, and possessions with large name signs. Promote a sense of belonging through displays of familiar personal items, such as old family pictures. "I feel strange." (e.g., side effects from medications that may include psychotropics, corticosteroids, beta-blockers, NSAIDs) Minimize the overall number of medications; consider nondrug interventions when possible. Begin new medications one at a time; start with low doses and titrate slowly. Suspect a drug reaction if the patient's behavior (e.g., vocal) changes. Educate caregivers about the patient's medications. "I need to be loved!" Provide human contact and purposeful touch. Acknowledge or verify the patient's feelings. Encourage alternative, nonverbal ways to express feelings, such as through music, painting, or drawing. Stress a sense of purpose in life, acknowledge achievement, and reaffirm that the patient is still needed.

Etiology

A definitive cause of AD, but a combination of genetic, environmental, and lifestyle factors influences a person's risk for developing the disease. There are multiple factors involved in the development and progression of this disorder Amyloid Precursor Protein The APP located on the cell membrane appears to have a neuroprotective role in situations of metabolic stress. During an acute stroke, cardiac arrest, or chronic hypoxic-ischemic condition, the APP can promote neuronal survival. When APP is cut or cleaved by the beta-site APP Cleaving Enzyme 1, neurotoxic amyloid-β is released. These peptides can accumulate as amyloid plaques, promoting neurodegeneration Beta-Amyloid Plaques One piece of the puzzle is partially explained by a leading theory that beta-amyloid plaques, made up of proteins, clump together in the brain and destroy cholinergic neurons. Research suggests that beta-amyloid deposits impair the normal function of pericytes, which are cells important for controlling the removal of protein from the brain. This leads to further accumulation of the protein. Beta-amyloid is hypothesized to interfere with the process of storing memories through interrupting synaptic connection. Symptoms such as aphasia and visuospatial abnormalities are attributable to plaque formation