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Delirium & Dementia-Class 1

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    DELIRIUM ANDDEMENTIA

    PSYCHIATRY

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    Definition Delirium is an acute confusionalstate,usually happening suddenly within

    hours or days.

    Its as a result of various physicalcauses,including infection,an endocrine

    disorder,trauma and drug abuse.

    Some of the causes are CHF,UTI,Liverfailure,electrolyte imbalances, use of

    psychotropics & anticholinergics

    (Benadryl,Elavil),alcohol withdrawal

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    Clinical features

    Disturbance of consciousness reduced ability to focus, sustain or shift attention

    Cognitive impairment memory deficits, disorientation (for time, place and person), language

    disturbances Perceptual disturbances

    misinterpretations, illusions and hallucinations (usually visual)

    Disturbance in sleep-wake cycle

    Altered psychomotor activity increased or decreased)

    Disorganized thinking with incoherence and delusions

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    Associated features

    Emotional disturbances common anxiety, depression, irritability, anger

    Neurological signs uncommon Abnormal movements, tremor, autonomic signs

    Disorders of higher cortical function Dysnomia(difficulty in naming objects),

    Dysgraphia(difficulty in writing)

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    Epidemiology

    Common condition especially children and elderly

    Pre-existing brain damage, drug or alcohol addiction,recovery from anaesthesia, coma

    Death rate varies: 10-30%, up to 50% in 1st year

    Delirium is a medical emergency, irrespective of age

    Course abrupt onset

    fluctuating characteristic with lucid intervals

    duration usually brief (dependant on identification and treatment ofunderlying condition)

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    Diagnostic criteria for Delirium The person has a reduced ability to maintain attention to external stimuli

    and to shift attention to a new stimuli. The person exhibits disorganized thinking as indicated by

    rambling,irrelevant or incoherent speech.

    The person experiences at least 2 of the following

    Reduced level of consciousness

    Perceptual disturbances-misinterpretations,illusions or hallucinations

    Increased or decreased psychomotor activity

    Disoriented to time place or person

    Memory impairment-inability to learn new material

    Clinical features develop over a short period and tend to fluctuate over theday.

    The history,physical examination or lab. tests show evidence of 1 or morespecific organic factors related to he disturbance

    It cannot be accounted for any other non-organic mental

    disorder(eg,agitation in mania)

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    NURSING DIAGNOSIS

    Disturbed thought processes related to changesin brain function.

    Impaired verbal communication related to

    incoherent speech. Dressing or grooming self care deficit related

    to inability to perform activities of daily living.

    Disturbed sensory perception (visual) relatedto disorientation

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    DELIRIUM (mnemonic) D -Disoriented(place,time & person)

    E -emotionally labile

    L -level of consciousness impaired,fluctuates

    I -Integration of perceptions is lost

    R-rapid onset(hours,days)

    I -irrelevant stimuli distract patient

    U -utterances(incoherent speech)

    M -memory impairment (especially immediate

    recent)

    Delirium may be life threatening and requires

    immediate medical attention

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    Treatment

    Specific measures

    Identify and treat the underlying

    conditionThorough medical history, physicaland neurological examination, lab

    tests

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    Treatment General measures

    Ensure sleep

    Maintain fluid and nutritional state

    Provide support and nursing care

    Rest in a quiet, well-lit environment

    Maintain orientation

    Sedate the agitated, fearful patient

    Offer soothing words and expressions of caring

    Do not argue ,do not reason

    Speak slowly and distinctly

    Provide a simple,consistent and predictable environment Provide familiar objects such as pictures,draw on old memories

    Help with orientation using clock and calendar

    Call patient by name

    Safety is the first priority

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    PROGNOSIS

    Is good

    Delirium can have various causes andusually goes away when the condition istreated

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    PREVENTIONS

    Avoid taking too many different types of drugs

    Recognize signs of delirium so treatment canbe started sooner

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    DEMENTIA

    It is a syndrome characterized by loss of

    intellectual abilities to such an extent that social

    and occupational functioning is interfered with. It

    involves memory, judgment, abstract thought and

    changes in personality

    Often the disorders are progressive and follow anirreversible course in which the damage remains

    permanent

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    ETIOLOGICAL FACTORS

    1.Neurological diseaseslike Huntingtons chorea, multiplesclerosis and Parkinson's disease.

    2.Cardiovascular disorders causing anoxia and brain damagee.g.cerebral arteriosclerosis and CVA.

    3.Central nervous system infection like viral encephalitis and

    fungal meningitis

    4.Brain trauma-chronic subdural hematoma

    5.Toxic-metabolic disturbances like bromide intoxication,hypothyroidism, Wilsons disease- hepatocellular degeneration

    characterised by deficient metabolism of copper 6.Loss of brain tissue and function in presenile conditions

    e.g. AD

    7.Alteration of intracranial pressure e.g hydrocephalus,brain tumor

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    CHARACTERISTICS

    Memory impairment and insidious loss of

    intellectual ability

    Onset tends to be gradual (such as from AD or

    AIDS)

    Progressive, static or recurring course, depends

    on pathogenesis

    Prevalence among elderly patients (but can

    occur in any age group)

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    SIGNS AND SYMPTOMS

    Short and long term memory impairment

    Premorbid personality changes

    Disturbed judgment Difficulty in understanding the meaning of

    words

    Confusion Depressed affect

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    DIAGNOSTIC CRITERIA

    A.The person shows demonstrable evidence of short

    and long term memory impairment B.He exhibits at least one of the following

    -Impairment in abstract thinking

    -Impairedjudgment

    -disturbances of higher cortical function like

    Aphasia-disorder oflanguage

    Apraxia-inability to carry out motor activities

    despite intact comprehension and motor functionAgnosia-failure to recognize or identify objects and

    constructional difficulty

    -Personality change

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    C. The disturbance in a& b significantly interferes

    with the the persons work or usual social activities or

    relationships with others. D.The disturbance does not occur exclusively during

    the course of delirium

    E.The disturbance meets either of the following

    criteria

    -history, physical examination or lab tests show

    evidence of one or more specific organic factors.

    -it is not accounted for by any non organic mentaldisorder (eg major depression accounting for

    cognitive impairment)

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    Diagnosis

    Loss of intellectual abilities that interfere with

    social and occupational functioning

    Memory impairment

    Impairment in abstract thinking,judgment and

    language

    Personality change demonstrated by

    exaggeration of previous personality traits

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    Health care professionals use the following criteria

    MILD: Work or social activities are significantlyimpaired but the capacity for independent living

    remains with adequate personal hygiene and intact

    judgment

    MODERATE: Independent living is hazardous and

    some degree of supervision is necessary.

    SEVERE: Activities of daily living are so impaired

    that continual supervision is required, the personcannot maintain minimal personal hygiene.

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    DEMENTIA

    A-apraxia

    M-memory impairment

    A-agnosia

    G-gradual onset & continual decline

    R-rule out delirium, substance abuse & medical

    conditions

    A-aphasia

    D-decline in social & occupational functioning

    E-executive function declines (ie, planning,

    organizing, sequencing)

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    FORMS OF DEMENTIA

    1.Alzheimers disease-most common

    2.Vascular dementia is sometimes known as

    multi-infarct dementia.It is related to an

    interruption of blood flow to the brain e.g.

    cerebral embolism, cerebral thrombosis. It isabrupt in onset and runs a variable course.

    3.Picks disease is a rare form of dementia that

    affects the frontal and the temporal lobes of thebrain.The clinical picture is fairly similar to

    AD but differences can be detected at autopsy

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    4.Creutzfeldt-Jakob disease(CJD) has symptoms that

    often include spasms of the body. It is caused by a

    slow acting virus that can live in the body for years

    before any signs of the disease become obvious .

    Once the signs of CJD become apparent its progress

    is rapid. 5.Huntingtons chorea is a genetically transmitted

    disorder transmitted by a single autosomal dominant

    gene. Personality, memory and mood changes as the

    disease advances. In later stages severe twitches,spasms and involuntary movement of the limbs

    become apparent.

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    ALZHIEMERS DISEASE

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    In 1906 Dr. Alois Alzheimer was first todescribe Alzheimer's disease.

    Since then millions of people have been

    diagnosed with the disease.

    Understanding

    Alzheimer's

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    A progressive, degenerative disease that

    attacks the brain and results in impaired

    memory, thinking and behavior.

    There is loss of intellectual functioning ,

    orientation, affective regulation, motor

    coordination and personality with eventual

    loss of bowel and bladder control to the point

    of total incapacitation

    What Is Alzheimer's

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    What Are the Warning Signs? Memory loss that affects job skills- recent

    Difficulty performing familiar tasks, short attention span Problems with language

    Disorientation to time and place

    Poor or decreased judgment

    Problems with abstract thinking

    Misplacing things

    Changes in mood or behavior, depression, paranoia,

    combativeness

    Changes in personality

    Loss of initiative

    Forgetfulness is the first symptom observed in A.D

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    Sundowners syndromeConfused , disoriented behaviour that becomes

    noticeable after the sun goes down and during the night

    Wandering behaviorRestlessness and activity seeking behavior

    The stalking of old haunts, night wandering

    Catastrophic reactions

    Heightened anxiety occurring during interviewing orquestioning when a person cannot answer or perform

    Incontinence

    Inability to perform ADL

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    What Causes Alzheimer's?

    Scientists are still not certain.

    Age and family history have been identified as

    potential risk factors. Researchers are exploring the role ofgenetics.

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    Does Alzheimer's Disease

    Occur in Younger Adults? Yes, though less frequently.

    The disease can occur in people in their 30s,

    40s and 50s. Most people diagnosed are older than 65.

    The form of the disease that strikes younger

    people accounts for less than 10 percent of allreported cases.

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    MANAGEMENT OF DEMENTIA

    1.Treatment is generally community focussed: The goal oftreatment is to maintain the quality of life as long as possible

    despite the progressive nature of disease. Effective treatment is

    based on:

    a.Diagnosis of primary illness and concurrent

    psychiatric disorders

    b.Assessment of auditory and visual

    impairment.

    c.Measurement of the degree, nature and

    progression of cognitive deficits

    d.Family and social system assessment.

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    2.Environmental strategies in order to assist inmaintaining the safety and functional abilities of the

    patient as long as possible.

    3.Pharmacological therapy: For patients of DATanticholinesterase medications is used to slow the

    progression of the disorder by increasing the amount of

    acetylcholine e.g. Donepezil (aricept), Tacrine (cognex).

    Other medications may be used for symptom reductionand behavioral control

    Agitation management- Neuroleptics

    Psychosis- neuroleptic agents

    Depression- antidepressants, ECT

    4.Hypertension management in vascular dementia is

    important in decreasing the severity of symptoms.

    5.Family education is very important

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    NURSING DIAGNOSIS Impaired communication related to cerebral impairment

    as demonstrated by altered memory, judgment and word

    finding.

    Self-care deficit related to cognitive impairment asdemonstrated by inattention and inability to completeADLs

    Risk for injury related to cognitive impairment andwandering behavior

    Impaired social interaction related to cognitive impairment

    Risk for violence:Self directed or directed towards othersdue to suspicion and inability to recognize people or places.

    Altered Family process related to impact of cognitivedeficits on traditional roles and functioning

    Caregiver role strain related to lack of support and level of

    care necessary for the patient.

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    NURSING INTERVENTIONTo provide a quiet structured environment to

    increase consistency and promote feeling ofsecurity Avoid dependency

    Establish routine for ADL

    Meet clients physical needs Do not isolate client from others in the unit

    Provide hand rails,walkers and wheelchairs

    Do not change schedule suddenly- routine,

    reinforcement and repetition are the key aspects ofcare

    Check for hazards in the environment (rugs on floor) makesure environment is well- lighted

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    To promote contact with reality Orient client frequently to reality and surroundings. Allow clients to have

    familiar objects around him/her. Use other items e.g.clock, calendar daily

    schedules Maintain reality orientation by encouraging reminiscing. Reminiscence and

    life review help the client resume progression through the grief process

    associated with disappointing life events and increase self esteem as

    successes are reviewed.

    Monitor the activities of a confused client

    Make brief and frequent contact.

    Give feedback

    Use simple explanations and face to face interaction. Do not shout message

    into clients ear. Speaking slowly and in face to face position is most

    effective when communicating with an elderly client experiencing a

    hearing loss.Visual cues facilitate understanding. Shouting causes

    distortion of high pitched sounds and creates discomfort in some clients.

    Allow sufficient time for client to finish projects.

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    To provide diversion activities that enhanceself esteem.

    Provide occupational therapy, physical therapy andrecreational therapy that the client enjoys.

    Maintain a flexible schedule: keep client from becoming boredand easily distracted.

    Recognize specific accomplishments.

    Encourage family involvement and provide support Devise methods for assisting client with memory deficits like

    Name sign and picture on door identifying clients room andthe other rooms.

    Large clock with oversized numbers and hands,appropriatelyplaced.

    Large calendar indicating one day at a time with month dayand year identified in bold print.

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    Ensuring safety

    Discuss restriction of driving

    Assess home for safety:keep house well lit, remove throw rugs, labelrooms.

    Assess community for safety

    Alert neighbors about patients wandering behavior

    Alert police and have current pictures taken.

    Provide patient with a Medic-Alert bracelet Install complex safety locks on doors to outside or basement.

    Install safety bars in bathroom.

    Closely observe patient if he or she is smoking.

    Encourage physical activity during the daytime

    Give the patient a card with simple instructions (address and phonenumber) in case he or she is lost.

    Use night lights

    Install alarm/sensor devices on doors

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    To improve the nutritional status

    Provide small, frequent feeds

    Serve finger foods/semi-soft/pureed foods

    Assess ability to swallow

    Use feeding aids when necessary

    Put the patient on a consistent meal schedule

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    The 3 Ps for clients with dementia Protecting dignity

    Preserving functioning

    Promoting quality of life

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    COMPLICATIONS

    Malnutrition/dehydration

    Pressure ulcers

    Muscle contractures Physical injuries

    Abuse

    Infection Death

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    AMNESTIC DISORDERS Short and long term memory impairment

    without clouding of consciousness orintellectual deterioration

    Result of a specific insult to the brain

    Anterograde memory loss- the patient cantremember events that occurred after the braininsult

    Retrograde memory loss- the patient cantremember events that occurredbefore the braininsult

    Confabulation is commonly used as a defense

    mechanism.

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    Signs and Symptoms

    Inability to recall recent events

    Inability to retain newly learned material

    Observable or laboratory test evidence of

    organic brain insult

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    Diagnostic criteria

    The person shows demonstrable evidence of short and long

    term memory impairmentShort-term memory impairment-indicated by

    an inability to remember 3 objects after 5

    minutes.

    Long-term memory impairment-indicated by

    an inability to remember personal information

    or facts of common knowledge

    The disturbance does not occur exclusively during the courseof delirium and does not meet the criteria for dementia

    The history, physical examination or lab tests show evidence

    of one or more factors judged to be etiologically related to the

    disturbance

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    Nursing Diagnosis

    Imbalanced nutrition: less than bodyrequirements related to nutrientdeficiency

    Impaired adjustment related to memoryloss

    Risk for injury related to inability to learn

    safety rules Compromised family coping related topoor family adjustment to the patients

    behavior

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    Nursing Intervention

    Monitor the patients food and fluid intake

    Supervise the patients travel away from home

    Establish a training program for relearning

    information needed to exist safely in the

    environment

    Institute memory therapy by teaching

    mnemonics

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