mental health - halter ch 23

alzheimer's disease: self assessment (nurse)

- make us aware of enormous responsibility placed on caregivers - have understanding of the disease so that expectations for the person are realistic - establish attainable outcomes for the person and recognizing when they are achieved

delirium: evaluation

- patient will remain safe - patient will be oriented to time, place and person by discharge - underlying cause will be treated and ameliorated

alzheimer's disease: diagnosis

- patient's safety is priority > risk for injury - impaired verbal communication - impaired environmental interpretation syndrome - impaired memory - acute/chronic confusion - disturbed sleep pattern - self-care deficit - anxiety - impaired social interaction - hopelessness for family members - they need support, education and sometimes referrals - caregiver role strain - anticipatory grieving - disabled family coping - interrupted family processes - grieving - hopelessness

alzheimer's disease: outcomes

- remains safe in hospital or home - sleep pattern is regular, balances rest & activity - self-car needs are met with optimal participation by patient - anxiety is reduced, acknowledges the reality of an object or sound after its pointed out - reports feeling safe, respond well to orientation interventions - communicates needs, connects with others at an optimal level with a variety of verbal and nonverbal methods - expresses feelings, demonstrates decreased preoccupation with loss family members: - express feelings in a supportive environment - have access to counseling and support groups - participate in care - utilize respite care

delirium: assessment

- should perform mental and neurological status exams & a physical exam - med regimen should be reviewed for interactions and toxicity profiles - lab data results should be reviewed - consider this diagnosis when patient abruptly demonstrates reduced clarity of awareness of the environment; ability to direct, focus, sustain or shift attention becomes impaired - may have to repeat questions - patient may get of track and need to be refocused - conversation is difficult because irrelevant stimuli may easily distract them - may have difficulty with orientation - 1) time, 2) place, 3) person - disorientation are worse at night and during early morning guidelines: - do not assume that acute confusion in an older adult is due to dementia - assess for acute onset and fluctuating levels of awareness - ass the person's ability to attend to the immediate environment including responses to nursing care - establish the person's usual level of cognition by interviewing family and other caregivers - assess for past cognitive impairment - especially an existing dementia diagnosis - and other risk factors - identify disturbances in physiological status, especially infection, hypoxia, and pain - identify any physiological abnormalities documents in the patient's record - assess vital signs, level of consciousness and neurological signs - assess potential for injury, especially in relation to potential for falls and wandering - maintain comfort measures, especially in relation to pain, cold or positioning - monitor situational factors that worsen or improve symptoms - assess for availability of immediate medical interventions to help prevent irreversible brain damage

delirium: DSM5 criteria

A. disturbance in attention and awareness B. disturbance develops over a short period of time, represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of the day C. additional disturbance in cognition such as memory deficit, disorientation, language, visuospatial ability or perception D. disturbances in criteria A or C are not better explained by another preexisting, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma E. there is evidence from the history, physical exam or laboratory findings that the disturbances is a direct physiological consequence of another medical condition, substance intoxication or withdrawal or exposure to toxin, or is due to multiple etiologies specify whether: substance intoxication delirium: diagnosis should be made instead of substance intoxication when the symptoms in criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention

major neurocognitive disorder: DSM5 criteria

A. evidence of significant cognitive decline from previous level of performance in one or more cognitive domain (complex attention, executive function, learning/memory, language, perceptual-motor or social cognition) based on: - concern of the individual, a knowledgeable informant, or clinician that there has been significant decline in cognitive function and - a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or in its absence, another quantified clinical assessment B. cognitive deficits interfere with independence in every day activities C. cognitive deficits do not occur exclusively in the context of delirium D. cognitive deficits are not better explained by another mental disorder

HIV infection dementia symptoms

a documented infection with HIV. impaired executive function, slowing of processing, problems with attention, difficulty learning new information, aphasia. symptoms dependent on area of brain affected by HIV pathogenic processes

huntington's disease symptoms

abnormal involuntary movements, severe decline in thinking and reasoning. mood changes such as irritability and depression, due to genetic defect

alzheimer's disease

accounts for 60-80% of all dementias often begins with worsening of ability to remember new information, marked by progressive deterioration in other cognitive functions like problem solving, learning new skills, decline in the ability to perform ADLs. this often leads to emotional changes like anxiety, mood lability and depression 3 stages: 1) mild or early stage > mild neurocognitive > loses energy, drive, initiative and has difficulty learning new things. personality and social ability remain intact > others tend to minimize/underestimate loss of abilities. depression often occurs during this stage. 2) moderate or middle stage > major neurocognitive 3) severe or late stage > major neurocognitive more severe symptoms of later stages include: - agnosia: inability to identify familiar objects or people - apraxia: loss of purposeful movement in absence of motor or sensory impairment - cannot remember location of toilet or unaware or process of urinating/defecating - world is very frightening and nothing makes sense > response is agitation, paranoia and delusions

delirium

acute cognitive disturbance and often reversible condition that is common in hospitalized patients, esp older. characterized as a syndrome (a constellation of symptoms) rather than a disorder cardinal symptoms: inability to direct, focus, sustain and shift attention; abrupt onset with clinical features that fluctuate with periods of lucidity, disorganized thinking and poor executive functioning other symptoms: disorientation (often to time and place, but rarely to person), anxiety, agitation, poor memory, delusional thinking. when hallucinations occur they are usually visual. associated with increased morbidity and mortality. can have long-term consequences such as permanent cognitive decline. ***medical emergency - needs attention immediately to prevent irreversible and serious damage

alzheimer's disease: epidemiology

attacks indiscriminately strikes men & women, various ethnicities, rich, poor and those with varying degrees of intelligence can occur at younger age (early onset), most of those with the disease are 65 y/o or older (late onset) 5.3 million Americans, 2/3 are women as women tend to live longer 1 in 8 people under 65 y/o 4% are younger than 65 15% between 65-74 44% between 75-84 38% are 85 or older

alzheimer's disease: intervention

attitude of unconditional positive regard is most effective tool > induces patients to cooperate with care, reduces catastrophic outbreaks and increases family members' satisfaction with care person-centered care: focuses on preservation of the personhood. based on ethical position that personhood remains and should be honored. focused on forming meaningful relationships with person who has dementia and their caregivers > maintains unique identity to person and promotes well-being. relationships must take priority over tasks. can significant decrease agitation. attempts to enter their world and provide care based on their unique life story > patient becomes more calm and relaxed pharmacological: FDA approved drugs are widely used and have shown to have statistically significant effects, only produce a clinically marginal improvement on cognition and function. benefits wane after 1-2 years. - cholinesterase inhibitor: donepezil (aricept), rivastigmine (exelon, exelon patch), galantamine (razadyne, razadyne ER) inhibits acetylcholinesterase, thereby increasing available acetylcholine modestly improves cognition in mind to moderate Alzheimer's dementia. donepezil also approved for severe. exelon patch approved for mild to moderate dementia of parkinson's. no evidence to support use in mild neurocognitive disorders, as no significant difference in progression to dementia. side effects are dose related > nausea, vomiting, diarrhea, insomnia, fatigue, muscle cramps, incontinence, bradycardia, syncope - N-methyl-D-aspartate (NMDA) receptor antagonist: memantine (namenda, namenda XR-slow release) regulates glutamate activity by blocking NMDA receptors thereby decreasing excitatory neurotoxicity caused by over stimulation of NMDA receptors by glutamate moderate to severe Alzheimer's; no evidence it modifies underlying disease side effects: dizziness, agitation, headache, constipation, confusion - NMDA receptor antagonsit/cholinesterase inhbitor: memantine/donepezil (namzaric) other meds for behavioral symptoms: "start low and go slow"; psychotropic meds, off-label antidepressants, anti-anxiety agents, anticonvulsants. integrative therapy: aromatherapy is used to promote relaxation and sleep, provide pain relief, and improve mood. can have inconsistent results.

cognitive functioning

basic lower-level: attention and orientation higher-level: plan and problem solve (executive function), learn and retain information in long-term memory, use language, visually perceive the environment - read social situations (social cognition)

dementia

broad term used to describe progressive deterioration of cognitive functioning and global impairment of intellect no change in consciousness does not refer to specific disease, but rather a collection of symptoms

delirium: epidemiology & risk factors

common complication of hospitalization - especially in older adults; 22% in general med patients, between 11-35% in surgical and up to 80% in ICU occurs 50% in patients over 65 y/o always due to underlying physiological cause that are usually multi-factorial and involve a dynamic interplay of factors - cognitive impairment - older age - severity of disease - infection - multiple comorbidities - polypharmacy - intensive care units - unaddressed orientation, visual or hearing issues - fractures - surgery - stroke - aphasia - vision impairment - restraint use - change in hospital rooms

delirium: physical needs

common dangers: wandering, pulling out IV lines, indwelling catheters, falling to of bed make environment as simple and clear as possible clocks and calendars can maximize orientation to time short periods of social interaction help reduce anxiety and misperceptions self-care deficits, injury, hyper- or hypo-activity can lead to skin breakdown and infection, and is compounded by poor nutrition, forced bed rest and incontinence autonomic signs such as tachycardia, sweating, flushed face, dilated pupils, elevated BP are usually present. sleep-wake cycle is usually disturbed. level of consciousness can range from lethargy to stupor or from semi-coma to hypervigilance.

alzheimer's disease: defense mechanisms

denial confabulation: creation of stories or answer in place of actual memories to maintain self-esteem preservation: persistent repetition of a word, phrase or gesture avoidance of questions

alzheimer's disease: symptoms

early: difficulty with recent memory, impaired learning, apathy, depression moderate to severe: visual/spatial and language deficits, psychotic features, agitation, wandering late: gait disturbance, poor judgment, disorientation, confusion, incontinence, and difficulty speaking, swallowing and walking agraphia: diminished ability and inability to read/write; occurs in early stage aphasia: loss of language; progresses from difficulty finding word to babbling or mutism apraxia: loss of purposeful movement in absence of motor or sensory impairment. results in ability to perform once familiar and purposeful tasks agnosia: loss of sensory ability to recognize objects hyperorality: tendency to taste, chew and put everything in mouth hypermetamorphiss: urge to touch everything sundowning: tendency for mood to deteriorate and agitation increase in later part of day or night - memory impairment - disturbances in executive functioning (planning, organizing, abstract thinking) - emotions begin to diminish

alzheimer's disease: health promo/teaching

educating family members is most important, need to know strategies for communicating and restructuring self-care activities. - referral to community supports: Alzheimer's Association, national agency, provides various forms of assistance to individuals with the disease and their families. include information regarding advance directives, durable power of attorney, guardianship, conservatorship in the communication with family. services that may be available: respite care, active case management, adult day care, physician services, protective services, recreational services, transportation, mental health services, legal services, home care like meals on wheels, home health aide services, homemaker services, hospice, OT, paid companion or sitter, PT, skilled nursing, personal care services, social work services, telephone reassurance, personal emergency response systems patient/family teaching guidelines for self-care: dressing/bathing, nutrition, bowel and bladder function,

alzheimer's disease: evaluation

frequent evaluation and reformulation of outcome criteria and short-term indicators help reduce staff and family frustration and minimize the patient's anxiety by ensuring tasks are not more complicated than the individual can accomplish - promote the person's optimal level of functioning - delay further regression whenever possible - provide family members with available resources and support may increase quality of life for both individual and family

alzheimer's disease: risk factors

genetics: immediate family member. 3 known genetic mutations that guarantee development of disease - account for less than 1% of all cases. these mutations lead to early-onset as early as 30 y/o. susceptibility gene has been identified for late-onset > makes the protein apolipoprotein E (APOE) which supports lipid transport and injury repair to brain. those carrying the E4 allele are increased, E3 allele is common, E2 allele decreases risk neurobiological: signs of neuronal degeneration that begins in hippocampus (recent memory) and spreads into cerebral cortex (problem-solving & higher order cognitive functioning) cardiovascular disease: linked to overall heart health, greater risk if have cardiovascular disease. head/traumatic brain injury: associated with greater risk social engagement/diet: should remain mentally and socially active and consuming healthy diet to prevent development and to keep brain healthy

alzheimer's disease: assessment

guidelines: - evaluate the person's current level of cognitive and daily functioning - identify any threats to the persons safety and security and arrange their reduction - evaluate the safety of the person's home environment if possible - review medications - interview the family to gain complete picture of the person's background and personality - explore how well the family is prepared for and informed about the progress of the person's dementia, depending on cause - discuss with the family members how they are coping with the patient - review the resources available to the family. determine if caregivers are aware of community support groups and resources - identify the needs of the family for teaching and guidance such as understanding sundowning diagnostic tests: brain imaging with CT or PET scan. use of mental status exams like mini-mental state exam. perform complete physical and neurological exam. obtain complete medical and psychiatric history, description of recent symptoms, review of meds, nutritional evaluation. observations and history provided by family members are invaluable

frontotemporal dementia symptoms

impaired social cognition, disinhibition, apathy, compulsive behavior, poor comprehension, language difficulties

mild neurocognitive disorder

impairments do not interfere with essential ADLs, but the person may need to make extra efforts. can be progressive, but not necessarily will progress to major

major neurocognitive disorder

impairments interfere with daily functioning and independence. often characterized by memory deficits

prion dementia symptoms

insidious onset, and rapid progression of impairment. motor features such as myoclonus or ataxia. memory, coordination behavior changes rapidly fatal

delirium: planning

involves special attention to safety and security of the environment. should ask: - does the person have necessary visual and auditory aids - are there family members available to stay with the patient - does the environment provide visual cues as to time of day and season of the year - has the person experienced continuity of care providers

delirium: moods/behaviors

may display motor restlessness (agitation) or may be quietly delirious and appear calm and settled. hyperactive delirium: agitation hypoactive delirium: no agitation behavior and emotions are erratic and fluctuating

delirium: cognitive and perceptual disturbances

mild: memory deficits are noticeable only on careful questioning severe: difficulty in processing and remembering recent events illusions: errors in perception of sensory stimuli. the stimulus is a real object in the environment - the individual misinterprets it and is often becomes an object of the patient's projected fear. you can explain and clarify for individual hallucinations: false sensory stimuli. visual is common, but tactile can be present too. generally aware something is wrong. emotional response is often fear and anxiety.

memory deficit: normal aging vs dementia

normal: - sometimes forgetting names/appointments but remembering them later - making occasional erros when balancing checkbook - occasionally needing help to use the settings on a microwave or to record a tv show - forgetting the day of the week but figuring it out later - vision difficulties related to cataracts or worsening night vision - sometimes having difficulty finding the correct word - misplacing things from time to time and retracing steps to find them - making a bad decision once in a while - sometimes feeling weary of work, family and social obligations - developing specific ways of doing things and becoming irritable when routine is disrupted dementia: - memory loss that disrupts daily life - challenges in planning or solving problems - difficulty completing familiar tasks - confusion with time or place - trouble understanding visual images or spatial relationships - new problems with words in speaking or writing - misplacing things and losing the ability to retrace steps - decreased or poor judgment - withdrawal from social and work activities - changes in mood and personality

vascular dementia symptoms

one or more documented cerebrovascular events. impaired judgment, poor decision making, planning and organizing (executive function), personality and mood changes

delirium: outcomes

patient will remain safe and free from injury while in the hospital during periods of clarity, patient will be oriented to time, place and person with the aid of nursing interventions such as a the provision of clocks, calendars, maps and other types of orienting information patient will remain free from falls and injury while confused with the aid of nursing safety measures

alzheimer's disease: moderate/middle stage

person confuses words, gets frustrated or angry, acts in unexpected ways. symptoms become noticeable to others - forget events or own personal history - become moody or withdrawn, especially in socially or mentally challenging situations - be unable to recall their own address or telephone number, or high school or college that they graduated from - become confused about where they are or what day it is - need for help choosing proper clothing for season or occasion - have trouble controlling bladder and bowels - change sleep patterns (sleep during day, restless at night) - be at risk for wandering and becoming lost - become suspiciousness and delusional or compulsive

alzheimer's disease: severe/late stage

person loses the ability to respond to their environment, carry on a conversation, and eventually to control movement. may still say words or phrases but communicating pain becomes difficult. personality changes may take place and individuals need extensive help with ADLs - require full-time, around the clock assistance with daily personal care - lose awareness of recent experiences and their surroundings - require high levels of assistance with daily activities and personal care - experience exchanges in physical abilities - walk, sit, swallow - have increasing difficulty communicating - become vulnerable to infections, especially pneumonia

delirium: nursing diagnosis

priority is safety needs ex: acute confusion, risk for deficient fluid volume, sleep deprivation, impaired verbal communication, self-care deficits, impaired social interaction

perception

processing of information about one's internal and external environment

cognition

represents a fundamental human feature that distinguishes living from excising. this mental capacity has a distinctive personalized impact on the individual's physical, psychological, social and spiritual conduct of life. has a direct relationship to ADLs.

substance/medication-induced dementia symptoms

symptoms of neurocognitive impairment persist beyond the usual duration if intoxication and acute withdrawal. substances include alcohol, inhalants, sedative, hypnotic, antianxiety agents

alzheimer's disease: mild/early stage

the person and loved ones notice memory lapses. person may still be able to function independently but will experience - difficulties retrieving correct words or names, previously known - trouble remembering names when introduced to new people - greater difficulty performing tasks in social or work settings - forgetting material that one has just read - losing or misplacing a valuable object - trouble with planning or organizing

traumatic brain injury symptoms

trauma to head with loss of consciousness, post-traumatic amnesia, disorientation and confusion and/or neurological signs

delirium: intervention

treatment priorities are to keep patient safe while attempting to identify the cause > preventing physical harm due to confusion; aggression or electrolyte and fluid imbalance; minimizing use of restraints as they increase confusion, assist with proper health management to eradicate underlying cause; use supportive measures to relieve distress **never leave patient in acute delirium alone

dementia with Lewy bodies symptoms

fluctuating cognition, early changes in attention and executive function, sleep disturbance, visual hallucinations, muscle rigidity, and other parkinsonian features

alzheimer's disease: planning

focuses on person's immediate needs - identifying level of functioning - assessing caregivers' needs

hypervigilance

patients are extraordinarily alert and eyes constantly scan room

neurocognitive disorders

profound disturbances in cognitive processing cloud or destroy the meaning of the journey - delirium: short-term and reversible - mild neurocognitive disorders: decline in cognitive functioning from previous level and differ how much they interfere with independence in ADLs. can progress to major - major neurocognitive disorders: commonly referred to as dementia, progressive and irreversible. decline in cognitive functioning from previous level and differ how much they interfere with independence in ADLs

parkinson's disease symptoms

progression of disease results in similar symptoms to dementia with Lewy bodies or Alzheimer's disease. apathetic, depressed or anxious mood, sleep disorder