V. Wright Adult i dementia delirium 14 with narative

BROAD CONCEPTBROAD CONCEPTCOGNITIVE IMPAIRMENT COGNITIVE IMPAIRMENT

DISORDERS:DISORDERS:DELIRIUM AND DEMENTIADELIRIUM AND DEMENTIA

PATHO/DELIRIUMPATHO/DELIRIUM

• Cognitive Impairment• If treat early enough is reversible• Characterized by clouding of the

consciousness, inability to focus & maintain attention, & altered perception

DELIRUMDELIRUM

• Occurs in 10-40% of hospitalized clients, 30-40% of hospitalized client with AIDS, & up to 60% of nursing home residents who are 75 years old & older.

• 80% of hospitalized clients near death will develop delirium.

• Occurs suddenly.

• CNS(central nervous system) affected by many conditions e.g. anemia, ischemia, hypoglycemia, lack of Vitamin B, endocrine disorders, toxicity from alcohol or drugs, trauma, infections, etc.

• Physical restraints may contribute

SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENTASSESSMENT

• Behavior: poor impulse control, may be withdrawn or agitated

• Speech: dull or rapid & pressured

• Picking at clothing and/or the air

• Bizarre behavior at night/Sundowner’s


• Affect:

• Range from apathy to irritability

• Labile emotions

• Laughing or sad


• Cognition: disorganized thinking (rambling speech) & ↓ ability to maintain & shift attention

• Visual hallucinations /altered perception are common

• Thinking, memory, attention and perception are disturbed



• Interpersonal Relationships: Families are anxious & frightened

• Physical: Sleep disturbance and tremors.

• Safety: Keep the client safe!

INTERVENTIONS

• Eliminate cause of delirium

• Monitor LOC continually

• Reorient with each interaction – introduce self and call client by their name

• Use short, simple, concrete phrases

• Keep the room well lit

• Provide clocks and calendars

• Have client use assistive devices (hearing aids/glasses

• Clarify reality while justifying emotions/feelings

EVALUATE EVALUATE PHARMOCOLGPHARMOCOLGY

• Depends on cause of delirium– Treat underlying cause first

• Haloperidol (Haldol) 1-2mg IV over 1-3 min may control symptoms. May be given with lorazepam (Ativan) IM

EVALUATE EVALUATE PHARMACOLOGYPHARMACOLOGY

• If EPS develops, give diphenhydramine (Benadryl) 25-50mg

DEMENTIADEMENTIA

• Alzheimer disease (AD) is behind 60-70% of late-onset dementias. Affects 4.8 million Americans

• $200 billion in U.S. spent yearly

• Affect 50% of persons over age 85

• Women more than men

• 15-20% are inherited

• Course is 5-10 years

CULTURECULTURE

• Cultural Influences:• In U.S ↑ risk for AD in Latin Americans & African

Americans• Japanese, Italians, & those from Hong Kong have

a greater risk in Europe & Asia• ↑ lower educational and socioeconomic levels• ↑clients with previous head injuries• ↑ clients with relatives that have AD

ETIOLOGIESETIOLOGIES

• Video: www.nia.nih.gov/alzheimers/ADvideo

• Genetics – cause is unknown, focusing on beta-amyloid protein that accumulates into plaques

• Early onset (30 to 60 y/o) is rare (5%) and is related directly to the Alzheimer’s gene

http://www.nia.nih.gov/alzheimers/ADvideo

ETIOLOGIESETIOLOGIES

• 1-Neurofibrillary tangles (twisted fibrils inside the neuron that disrupt cellular processes and eventually kill the cell)

• 2-Plaques (it is the quantity of plaques in relation to the person’s age that is significant) (a) widened sulci and narrowed gyri

AD

• AD affects:– Communication, metabolism, and repair

process of neurons in the brain

• Which causes:– Memory failure– Personality changes– Difficulty carrying out ADLs• There is a progressive decline

ADAD

• 4 stages

• Mild – lasts 2-4 years

• Moderate – longest stage, day care may be necessary

• Moderate to Severe AD – lasts 1-2 years, 24/7 care needed

• Late/End stage

Stage 1 (Mild AD)

• Mild – lasts 2-4 years:

• characterized by– Short-term memory loss– Uses memory aids such as lists and

routine– Aware of the problem– Depression is common– NOT diagnosable at this stage

Stage 2 (Moderate AD)• Stage 2 Moderate AD is characterized by:

– Progressive memory loss– Withdrawn from social activities– Decline in instrumental ADLs (money

management, cooking, driving)– DENIAL – fears “losing” his/her mind– Depression– Confabulation – Symptoms worsen with physical/emotional stress

Stage 3 (Moderate/Severe AD)

• Stage 3 Moderate to Severe AD is characterized by:– ADL losses: willingness to bathe, grooming,

choosing clothing, toileting, communication, reading/writing

– Loss of reasoning ability– Depression resolves as they become unaware of

loss– Difficulty communicating– Usually institutionalized or need care 24/7

Stage 4 (Late / End stage)

• Stage 4, late / end stage AD is characterized by:– Family recognition/self recognition disappears– Non-ambulatory– Forgets how to eat, swallow, chew, wt loss– Incontinent– 24/7 care required– Return to infantile reflexes and ultimately Death

• Death usually secondary to infection or choking

7 WARNING SIGNS of AD7 WARNING SIGNS of AD

• Asking the same questions over & over

• Repeating the same story, word for word, again & again

• Forgetting how to cook, or how to make repairs, or how to play cards – activities that were previously done with ease

• Losing one’s ability to pay bills or balance one’s checkbook

7 WARNING SIGNS of AD7 WARNING SIGNS of AD

• Getting lost in familiar surroundings

• Neglect to bathe, or wearing the same clothes over & over while insisting they are clean & are wearing dirty clothes

• Relying on someone else close to them to make decisions or answer questions that they used to handle

OTHER DISORDERSOTHER DISORDERS

• Pseudodementias - mimic dementia

• Causes:

• Drug toxicity

• Infections

• Metabolic disorders

• Nutritional deficiencies

• Depression- most common cause

EVALUATE EVALUATE PHARMOCOLOGYPHARMOCOLOGY

• DONAZEPIL (Aricept) 5mg P.O. daily @ bedtime. After 4-6 weeks↑ to 10mg

• Classification: cholinesterase inhibitor• Action: improves cholinergic function by

inhibiting acetylcholinesterase• Improves cognitive function• *Missed doses should be skipped and

regular schedule returned to the following day.


• Rivastigmine (Exelon) 1.5 mg. twice a day with food, may ↑ by 1.5 mg. twice a day every 2 weeks if tolerated. Target dose 3 – 6 mg. twice a day. Max. dose 12 mg twice a day

• Classification: Cholinesterase Inhibitor

• Action: Treats mild to moderate AD


• Galntamine (Reminyl) 4 mg. twice a day for at least 4 weeks, if tolerated may ↑ by 4 mg. twice a day every 4 weeks. Target dose 12 mg twice a day.

• Classification: Cholinesterase inhibitor

• Action: treat mild to moderate dementia

EVALUATE EVALUATE PHARMACOLOGY PHARMACOLOGY

SE: HA, diarrhea, nausea, sweating, bradycardia, & insomniaNSG: Taking after breakfast may lessen side effects, teach how family how to monitor pulse*Do not cure – only slows down the disease


• memantine HCL (NAMENDA)

• Used in moderate to severe Alzheimer’s or with an acetylcholinesterase – less GI disturbance

• Side effects: dizziness, HA, confusion and constipation

MULTIDISCIPLINARY INTERVENTIONS

• Speech therapy

• Physical therapy

• Occupational therapy

• Social workers

• Pastoral counselors

• New hope is gene therapy – new nerve growth

ALTERNATIVE THERAPIESALTERNATIVE THERAPIES

• Antioxidants – found in green tea, grape seed extract, deepest color fruits & veggies

• Omega-3 Fish Oil – found in salmon, mackerel, sardines

• Phosphatidyl Serine – keeps nerve cells flexible

• Melatonin – for sleep• Estrogen – may be preventative in women

(not useful in existing dementia)


• Dehydroepiandrosterone (DHEA) – regulates mood

• S_adenosylmethionine (SAMe) – improves cell membrane flexibility, caution in people with cardiac history

• Lecithin – found in soybeans & eggs• Ginkgo Biloba –increase risk for bleeding


• Music– What type of music would be appropriate?

• Touch– How should a client with dementia

touched? What approach should the nurse take?

• Animal-Assisted– Assess for fears first, if possible

• Behavior: Wandering, unable to do complex tasks, frightened by their confusion, attempt to cover up symptoms, need assistance dressing

• ↑ appetite & food intake – no ↑ in weight

• Repetitive behaviors – lip smacking, pacing

• Sundown Syndrome – disoriented at days’ end. Orientated in day.



• Affect:

• Mild stage: anxiety & depression occur

• Moderate stage: ↑ lability of emotions (rage, irritability)

• Severe stage: person becomes unresponsive to environment


• Cognition: ↓ in concentration, ↑ distractibility, absent-mindedness, unable to make judgments

• Language skills begin to deteriorate

• Difficulty word-finding

• In mod AD – memory loss (recent & remote)

• Confabulation: filling in gaps with imaginary information

• Misidentification syndrome – familiar people are unfamiliar

• Aphasia – unable to understand language

• Agraphia – unable to read or write

• Agnosia – unable to recognize familiar people or situations

• Alexia – unable to tell what to do with a frying pan, toothbrush, telephone

SYSTEM SPECIFIC SYSTEM SPECIFIC ASSESSMENT - COGNITIONASSESSMENT - COGNITION


• Perception: visual hallucinations most common– What would our intervention be?

HIGHER NEEDSHIGHER NEEDS

• Can you think of some problems with clients & AD as they try to fulfill their higher needs? Which ones would be affected?– What would some interventions be to help

address these higher needs?

NURSING CARENURSING CARE

• Safety is first priority for delirium & dementia– What are some interventions we can do

address the safety issues for clients with delirium and dementia?

• Find local resources such as _________

NURSING CARENURSING CARE

• What are some interventions that you can think of for someone suffering from AD?

• How would you assist families?

Diagnostic Tools

• No definitive test

• PET

• MRI

• SCT and PET

• MSE

Date post:	22-May-2015
Category:	Health & Medicine
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V. Wright Adult i dementia delirium 14 with narative

Health & Medicine