Nursing 4- Mental Health Exam

Assessment of pt. with NCD

*Areas of concern to be addressed* -Type, frequency, and severity of mood swings -Personality and behavioral changes -Catastrophic emotional reactions -Cognitive changes -Language difficulties -Orientation to person, place, time, and situation -Appropriateness of social behavior -Current and past use of medications, drugs, and alcohol -Possible exposure to toxins -Client and family history of specific illnesses -*neuro exam* assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination -labs

temporary dementia can occur from

*Reversible NCD* Secondary NCDs from -stroke -depression -SE of meds -nutrition deficiencies -metabolic disorders

define delirium

*rapid change in congnition* mental disorder marked by confusion; uncontrolled excitement; ADJ. delirious awareness changes along with a change in cognition

define abuse

- An act or failure to act that intentionally or recklessly causes harm to a resident (W13) - Purposely causing physical, mental, or emotional pain or injury to someone (H13)

why do people abuse elders

- Perpetrator - victim dependency - Perpetrator deviance - Victim vulnerability - Caregiver stress - Social isolation - Ageism - Inadequate resources - Lack of knowledge of the problem -elders are living longer -they learned it from their past childhood

NCD due to traumatic brain injury

-*Amnesia is the most common* neurobehavioral symptom following head trauma. -Repeated head trauma can result in dementia pugilistica with symptoms of: Emotional lability Dysarthria Ataxia Impulsivity

Types of dementia

-Alzheimers Disease -Vascular Dementias -Lew Body Dementia -Fronto Temporal Dementias -Other Dementias

As NCD progresses, symptoms may include:

-Aphasia (loss of ability to understand or express speech, caused by brain damage.) -Apraxia (inability to perform particular purposive actions, as a result of brain damage.) -Irritability and moodiness, with sudden outbursts over trivial issues -Inability to care for personal needs independently -Wandering away from the home -Incontinence

nonverbal signs of abuse

-Avoids eye contact -Nervous/ Fearful -Quiet and passive -Sits a distance from the caregiver -Cringe/ startle easily -Allow the caregiver to respond/answer questions

NCD due to Parkinson's disease

-Caused by a *loss of nerve cells located in the substantia nigra and a decrease in dopamine activity* -Cerebral changes in NCD due to Parkinson's disease sometimes resemble those of Alzheimer's disease

NCD due to HIV infection

-Caused by brain infections with opportunistic organisms or by the HIV-1 virus directly. -Symptoms may range from barely perceptible changes to acute delirium to profound cognitive impairment.

NCD due to Huntington's disease

-Huntington's disease is transmitted as a *Mendelian dominant gene* -Damage occurs in the areas of the *basal ganglia and the cerebral cortex.* -The client usually declines into a profound state of *dementia and ataxia.* (lack of muscle coordination -Average course of the disease is based on age at onset, with juvenile-onset and late-onset having the shortest durations.

culturally, people don't seek help because

-Language Barriers -Unable to access services -Financial Difficulties -Stigma/Shame -Keeping Problems from Outsiders -Mistrust of the Mainstream Services

Vascular NCD

-NCD occurs as a result of significant cerebrovascular disease -There is a more *abrupt onset* than is seen in association with Alzheimer's disease, and *the course is more variable* -Etiologies may include: *hypertension, cerebral emboli, cerebral thrombosis*

guilty caregivers (abuser)

-Nervous when questioned -Try to prevent private conversation with the elderly person -Give explanations for injuries that do not seem to make sense -Impatient, irritable, negative, demeaning statements about the elderly person

Substance induced NCD

-Occurs as a result of reactions to, or the overuse or abuse of, substances such as: Alcohol Inhalants Sedatives, hypnotics, and anxiolytics Medications that cause anticholinergic side effects Toxins, such as lead and mercury

Frontotemporal NCD

-Occurs as a result of shrinking of the frontal and temporal anterior lobes of the brain -Previously called Pick's disease -Exact cause is unknown, but genetics appears to be a factor

how to recognize sexual abuse

-Pain or itching in the genital region -Bruising or bleeding in external genitalia, vaginal, anal areas -Unexplained sexually transmitted disease -Vaginal drainage

Lew body dementia

-Protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement (motor control). -lewy bodies are present upon autopsy

DCF

-Provide service to detect and correct abuse, neglect or exploitation -Place few restrictions on personal liberties and rights -DCF can not forcibly remove a competent adult from a situation he or she refuses to leave -Only if the person is mentally impaired and the worker intervene. -Law enforcement takes the lead in all criminal investigations and prosecutions

NCD due to Lewy body disease

-Similar to Alzheimer's disease, but progresses more rapidly -*Appearance of Lewy bodies in the cerebral cortex and brainstem* -Progressive and irreversible -May account for 25 percent of all NCD cases

NCD due to Prion disease

-The disorder is attributable to prion disease (e.g., Creutzfeldt-Jakob disease or bovine spongiform encephalopathy). -Onset of symptoms typically occurs between ages *40 and 60 years; course is extremely rapid, with progression from diagnosis to death in less than 2 years.* -Five to 15 percent of cases have a genetic component.

how to recognize physical abuse

-Unexplained injuries -Injuries for which the explanation does not make sense -Old wounds/ fractures -Bruises/welts/scars found on both sides of the body (bilateral) -Broken eyeglasses -Signs of being restrained- wrist/ ankle/ chest marks -Burns

how to recognize neglect

-Unexplained skin rashes -Inappropriate clothing -Malnutrition- hunger -Poor hygiene -Lack of medication- medical treatment -Left in unsafe situation

*Report to Charge nurse* 180096ABUSE

-Vulnerable adults -Change in behavior, sleep -Depressive symptoms -Obvious bruise, lacerations, -Genital complaints -Unexplained, insufficient funds

what is it like to report abuse

-You may remain anonymous -Calls are recorded -Fax or Web reporting

Common signs of NCD

-appearance and hygiene are neglected -maybe impulsive and have lack proper social conduct -language may or may not be affected -personality change is common

Vascular Dementias

-caused by stroke, hyptertension or other problems that interfere with oxygen supply to brain -due to loss of brain cells when blood vessels in brain are damaged -the 2nd most common type of dementia

What are the symptoms of a pt. with delirium

-recent memory impaired -misperceptions about the environment with illusions and hallucinations -disturbed LOC -interrupted sleep wake cycle -fluctuation of Agitation, restlessness and vegetative state (emotionally unstable)

nursing interventions for elder abuse

-speak to the individual alone -ensure safety -build rapport and trust -know the policies -refer to stress group -provide respite -report!! -know the names and phone numbers of nearby assistance

What are the autonomic symptoms of delirium

-tachycardia -sweating -flushed face -dilated pupils -high blood pressure

Lithium blood levels

0.6-1.2

most common risk factors for elder abuse

10% over 65 Over 70 white, female, impaired, unable to meet needs on own

Lithium blood testing rules

8 hrs after last dose, 5 days after beginning dose, dosage changes, then testing for 6 months monthly

the most common type of dementia is

Alzheimer's disease

who is obligated to report abuse

Any person who knows or has reasonable cause to suspect that a vulnerable adult is being abused, neglected or exploited shall report it to the Florida abuse hotline

Other dementias

Associated with PD, Huntingtons, HIV, alcohol related,

elder abuse demographic

Avg age 77-78 more white than black more black than hispanics

Diagnostic Labs and evaluations for NCD

Blood and urine -Various infections -Hepatic and renal dysfunctions -Diabetes or hypoglycemia -Electrolyte imbalances -Metabolic and endocrine disorders -Nutritional deficiencies -Presence of toxic substances *Electroencephalogram *Computed tomography scan *Positron emission tomography *Magnetic resonance imaging *Lumbar puncture to examine cerebrospinal fluid

Hospitalized and diagnosed in the fourth stage of NCD due to AD, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting?

Confabulation is a behavioral reaction to memory loss in which the client fills in memory gaps with information about events that have not occurred.

Which statement is true about vascular dementia? a-Vascular dementia is reversible. b-Vascular dementia is characterized by plaques and tangles in the brain. c-Vascular dementia involves a gradual, progressive cognitive deterioration. d-Vascular dementia involves a variable pattern of cognitive functioning.

D Vascular dementia involves a variable pattern of cognitive functioning.

General Medical Condition Delirium

Delirium caused by another medical illness: *Infections*, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, and others

what is DCF

Department of Children and Families

unintentional neglect

Failure to provide/meet needs due to ignorance/infirmity is inadvertent ex: (didn't know better)

Proper questions to ask person suspected of abuse

Has anyone close to you tried to hurt or harm you? Do you feel comfortable with those caring for you? Has anyone said you cause a lot of problems? Do you feel wanted? Has anyone touched you in a way you don't want touched?

Substance-induced Delirium

May be caused by intoxication or withdrawal from certain *substances* such as: Anticholinergics, antihypertensives, corticosteroids, anticonvulsants, analgesics, and others Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, and others Toxins, including organic solvents and fuels, lead, mercury, arsenic, carbon monoxide, and others

nursing education for dementia

Nature of the illness•Possible causes•What to expect•Symptoms •Management of the illness•Ways to ensure client safety•How to maintain reality orientation•Provide assistance with activities of daily living•Nutritional information•Difficult behaviors•Medication administration•Matters related to hygiene and toileting •Support services•Financial assistance•Legal assistance•Caregiver support groups•Respite care•Home health care

define perpetrator

One who has committed a crime (offender

types of elder abuse

Physical abuse Sexual abuse Psychological or emotional Neglect Abandonment Financial or material exploitation

Mandatory reporting of abuse, neglect, or exploitation of vulnerable adults; mandatory reports of death.—(1) MANDATORY REPORTING.—(a) Any person, including, but not limited to, any:1. (2013 Florida Statutes) 415.1034

Physician, osteopathic physician, medical examiner, chiropractic physician, nurse, paramedic, emergency medical technician, or hospital personnel engaged in the admission, examination, care, or treatment of vulnerable adults;

Frontotemporal NCD is also known as

Pick's

An interaction/conversation with a pt. of delirium will probably go like this...

Pt. will not be able to pay attention, they will be easily distracted and have disorganized thoughts. When they talk they ramble, and have no real conversation with meaning their reasoning is off but they have goal directed behavior. They're usually disoriented to time and place

Define neurocognitive disorder

Significant deficit in cognition or memory exists representing a big change from a previous level of functioning

What are the first 3 stages of AD

Stage 1: *No apparent symptoms* -Early (mild): first symptoms up to 4 years -independent with ADLs -no social/employment problems initially -denies presence of symptoms -forgets names; misplaces household items -short term memory loss; difficulty recalling new information -subtle changes in personality and behavior -mild cognitive impairment, problems with judgment Stage 2: *forgetfulness) -moderate (2-3 years) -impairment of all cognitive functions -problems with handling or unable to handle money and finances -disorientation to time, place, and event -possible depression, agitated -increasingly dependent with ADLs -visuospatial deficits: difficulty driving, gets lost -speech and language deficit -incontinent -wandering; trouble sleeping Stage 3: *mild cognitive decline* -severe -completely incapacitated; bedridden -totally dependent in ADLs -motor and verbal skills lost -general and focal neurologic deficits -agnosia (loss of facial recognition)

Stages of AD

Stage 1: No apparent symptoms Stage 2: Forgetfulness Stage 3: Mild cognitive decline Stage 4: Mild-to-moderate cognitive decline Stage 5: Moderate cognitive decline Stage 6: Moderate-to-severe cognitive decline Stage 7: Severe cognitive decline

define abandonment

The discontinuation of care without proper notice

What functions are impaired in NCD

The fx of abstract thinking, reasoning, memory, learning and speaking

Alzhiemer's Disease

a condition in which one gradually loses their memory. It is the most common type of dementia

Alzhiemer's disease (AD)

a slow and insidious disorder that is progressive and deterioration The predisposing factors include: -Acetylcholine alterations -*Plaques and tangles* -Head trauma -Genetic factors

Donepezil (Aricept)

acetylcholinesterase inhibitor for alzheimer's disease Donepezil is used to improve cognition in clients diagnosed with mild to moderate dementia associated with Alzheimer's disease. Its action improves cholinergic function by inhibiting acetlycholinesterase.

Alzheimer's disease (AD) accounts for the majority of

all cases of NCD

physiological abuse

any behavior that causes a person to feel threatened, fearful, intimidated, or humiliated in any way ex: (intimidation, humiliation/ridicule, blaming, ignoring, isolating, terrorizing)

sexual abuse

any sexual act without consent

treat substance induced delirium with

benzodiazepines

Secondary NCDs

caused by or *related to another disease or condition* (e.g., HIV disease or cerebral trauma)

the incidence of elder abuse is

climbing. Verified cases are becoming more prominent and more people are getting charged.

Fronto-temporal dementia (FTD)

degeneration of nerve cells in the Frontal and Temporal lobes = socially inappropriate behavior

intentional neglect

deliberate failure to do the obvious necessary things for an elder ex: (administer medications or withhold transportation to MD appointment)

medical treatment of primary NCD

focus on etiology try to reverse what you can

when can DCF remove a person out of a situation, when can they not

if the pt. is competent they can not be removed if the person is mentally impaired and cannot make logical decisions DCF can remove them

Aphasia

impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to Wernicke's area (impairing understanding).

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

physical abuse

intentionally causing physical harm to another person ex: (shoving, hitting, inappropriate use of drugs, restraints)

in which location does most abuse occur

it can occur anywhere, literally but it mostly occurs at home and then senior care facilities

what is the main form of out of the home living environment abuse

lack of adequate staff to properly care for the patients

ataxia

lack of muscle coordination

In the second stage of AD what is common,

losses in short-term memory are common and the individual may begin to lose things or forget names of people. It's at this stage that a diagnosis may be considered.

During the 4th stage of Alzheimer's dementia, a client will use confabulation in an effort to

maintain self-esteem.

2. A client is newly diagnosed with secondstage NCD due to AD. Which cognitive change would a nurse observe? 1-Memory disturbance 2-Confabulation 3-Apraxia 4-Inability to plan or organize

memory disturbance

Mild NCD has also been called where as major NCD was previously described as

mild cognitive impairment ; dementia

NCD maybe classified as

mild or major

what is the most common form of elder abuse

neglect

trazadone

no sleep walking better for elderly

what is exploitation of a vulnerable adult?

normally financial

dementia is an umbrella term that describes a collection of symptoms. it is not

one specific disease

what is the second most common elder abuse

physical abuse

What is the onset of delirium

rapidly over a short period of time Usually begins abruptly and ends briefly *Rapid onset of hours -> days* (if slower it may be due to a medical condition)

granny dumping

refers to adult children or grandchildren, burdened with the care of their elderly parent or grandparent, ex- leaving the elder at the entrance of a hospital with no identification

In vascular dementia, clients suffer the equivalent of

small strokes that destroy many areas of the brain. *The pattern of deficits is variable*, depending on which regions of the brain have been affected.

Reversible NCD

temporary dementia

elder abuse

the abuse or neglect of older family members

financial abuse

the act of stealing, taking advantage of, or improperly using the money, property, or other assets of another (misuse of checks/credit cards, stealing cash, forging signatures, identity theft)

Primary NCDs

the disorder itself is the major sign of some *organic brain disease not directly related to any other organic illness* (e.g., Alzheimer's disease)

define confabulation

the unintended false recollection of episodic memories

elders get murdered by which more

their offspring t 42% over theur spouses by 24%

how to treat delirium

treat underlying cause remain with client at *ALL* times reorient and reassurance low stimulus room low dose antipsychotic benzos are commonly used for substance withdrawal

seroquel

typically used for elders

common characteristics of the perpetrator

usually a relative, caretaker, under financial stress, substance abuser, over 50% of the time it is a female who is in her 40s

typical behavior of a elderly person being abused

usually downplay it or deny that it is happening at all they prefer not to disclose. they allow it to continue to happen because they are dependent, learn the behavior

Pharmaceutical agents for cognitive impairment in NCD

•Physostigmine (Antilirium) •Tacrine (Cogex) *•Donepezil (Aricept)* •Rivastigmine (Exelon) •Galantamine (Razadyne) *•Memantine (Namenda)*