Cognitive Disorders ECT
Phyllis M. Connolly, PhD, RN, CSNURS 127A
Questions for consideration
• What are the similarities and differences between delirium, dementia, and depression?
• What is a catastropic reaction and what interventions are helpful?
• What is a positive client outcome for altered thought processes?
• What the indications for ECT?
Cognitive Impairments• 2.4 million Americans suffer from
dementing illnesses• 7.3 million by 2040• Alzheimer’s Disease• Dementias
– Vascular--interruption of blood flow to brain– Parkinson’s--involves extrapyramidal– Diffuse Lewy Body Disease– Huntington’s Disease
• Creutzfeldt-Jakob Disease• Alcoholic Dementia • TIA
Medications Causing or Contributing to Dementia or Delirium• Analgesics
– Codeine– Meperidine– Morphine– Pentzcocine– Indomethacin
• Antihistamines– Dephenhydramine– Hydroxyzine
• Antihypertensives– Clonidine– Hydralazine– Methyldopa– Propranolol– Reserpine
• Antimicrobials– Gentamicin– Isoniazid
Medications Causing or Contributing to Dementia or Delirium Cont.• Antiparkinsonism
– Amantadine– Bromocriptine– Carbidopa– L-Dopa
• Cardiovascular– Atorpine– Digitalis– Diuretics– Lidocaine
• Hypoglycemics– Insulin– Sulfonyureas
• Psychotropics– Benzodiazepines– Lithium– Tricyclics– Haloperidol– Thiothixene– Chlorpromazine– Barbituates
– Chloral hydrate
• Others– Cimetidine– Steroids– Trihexyphenidyl & other
anticholinergics
Dementia• Constellation of symptoms resulting
in impairment of short and long term memory
• Onset slow or insidious• Progressive ends in death• Deterioration in judgment & abstract
reasoning• Social & occupational functioning
significantly affected• Most common cause Alzheimer’s
Four As of Alzheimer’s Disease• Amnesia--inability to learn new
information or to recall previously learned information
• Agnosia--failure to recognize or identify objects despite intact sensory function
• Aphasia--language disturbance that manifest in both understanding & expressing the spoken word
• Apraxia--inability to carry out motor activities despite intact motor function
Alzheimer’s: Etiology• Senile plaques & neurofibrillary
tangles• Dystrophic neurites(thickened,
swollen neuronal processes)• Abnormal amyloid deposits• Genetic--10-15% of cases• Toxin model--aluminum salts• Infectious agent model--virus• Cholinergic deficit model
Alzheimer’s Disease: Behavioral Symptoms• Hallucinations• Delusions• Dysphoria &
depression• Fearfulness• Repetitive
purposeless acts• Avoidance
behavior
• Motor restlessness• Apathy• Verbal and physical
aggression• Resistance to
interventions– Hygiene– Nutrition– Safety
Stressors for Persons with Cognitive Impairments• Fatigue• Change of environment, routine or
caregiver• Overwhelming or competing stimuli• Demands that exceed capacity to
function• Physical stressors
Catastropic Reaction
• Excessive distress exhibited by patients in situations that are confusing or frightening ex. Showering
• Interventions– Remain calm– Remove patient from whatever is
upsetting– Use distraction rather than confrontation
Impaired Cognitive Functioning• Key Elements of Care
– Communication– Orientation– Structure– Stimulation– Safety
Altered Thought Processes• Client Outcomes
– Demonstrates improved reality orientation– Responds coherently to simple requests– Follows simple directions
• Interventions– Baseline mental status & functioning– Avoid making demands– Ask only one question & make only one request at a
time– Provide a structured routine– Provide familiar objects– Avoid agreeing with confused thinking but DO NOT
ARGUE--try to distract– Incorporate orientation cues from the environment– Keep environment simple & uncluttered
Delirium• Alterations in consciousness• Changes in cognition• Usually caused by medical condition or substance
induced• Develop over short period of time• Treatable• 30% CCU environments, “CCU psychosis”• Disoriented• Disorganized thinking and speech• Altered perceptions: illusions, delusions & hallucinations• EEG changes• Neurological abnormalities
Delirium: Treatment• Identify & correct cause
– anemia– dehydration– nutritional deficiencies– electrolyte imbalance
• Monitor closely• Safety high priority• Control behavioral symptoms• Well lighted room, visible clock &
calendar
Comparison Dementia, Delirium & DepressionDementia Delirium Depression
Cause may beunknown
Cause may beidentified
Cause may beidentified
Can becomechronic
Time limited Time limited
Insidious Acute onset Insidious
Not often treatableor reversible
Always treatable Usually treatable
Consciousness,normal
Clouded Normal
Psychotherapeutic Management
• Nurse-Patient Relationship• Psychopharmacology
– Antipsychotics– Antidepressants– Antianxiety– Treatment of cognitive impairment
• cholinergic enhancers• metabolic enhancers/vasodilators• Nootropic agents
– Milieu management• Safety
Validation Therapy
• Enter client’s world rather than force to relate to an external world which is no longer comprehensible
• Increase the client’s sense of being understood by others
• Reduces agitation and catastrophic reaction
quality of lifeSchober, Glod, Jones, 1998, p .252
Tips for Working with Persons with Dementia
• Person wears identification bracelet
• Install special locks, safety devices on doors, stove & other potentially dangerous objects
• Check frequently for burns, bruises, or abrasions
• Assess for signs of abuse
• Only use restraints after other methods are ineffective--need MD order
• Look directly at person when speaking
• Identify yourself prior to interaction
• Use simple short phrases• Ask specific rather than
general questions• Distract if asking same
question repeatedly• Assist in word finding• Reassure that you intend to
help• Avoid arguing• Convey patience and
understanding
Promote Safety Communication
Tips for Dementia Care Cont.
• Establish regular & predictable routine
• Breakdown complex tasks into small simple steps
• Consistent care by regular staff
• Use large clock & calendar distraction & stimulation,
avoid clutter & unnecessary objects
• Post lists of daily activities• Person wear glasses &
hearing aid• Avoid medications if
possible• Check person frequently
Decrease Confusion
Tips for Dementia Care Cont.
• Encourage regular exercise
• Ensure nutrition & hydration
• Assist with ADLs• Assess frequently for
physical pain, constipation, & discomfort
• Evaluate agitation and worsening behavior carefully
• Suggest day treatment for clients living at home
• Teach ways to manage uncooperative behavior
• Teach about causes and course of dementia
• Monitor & assess level of stress on the family
• Encourage use of social support to decrease caregiver stress
• Help families mourn the loss of their loved one
Physical & Emotional Wellbeing
Family Education
Schober, Glod, Jones, 1998, p. 251
Modern ECT• Causes changes in monoamine
neurotransmitter system• Electric current (70 - 150 volts) passes
through the brain from .5 to 2 seconds• Seizure must last approximately 30 - 60
seconds for therapeutic value• ECT has cumulative effect, needing 220 -
250 seconds• Oximeter-monitor anesthetic to assure
oxygenation• 2 - 3 times/week up to 6 - 12 treatments• May require periodic or maintenance ECT
treatments
Disorders, Depressive Symptoms, & Conditions Responding to ECTDISORDERS DEPRESSIVE
SYMPTOMSCONDITIONS
Severe depression85 – 90%
Anhedonia Tardive dystonia
Treatment-refractorydepression
Anorexia Tardive dyskinesia
Catatonia Delusions Akathisia
Mania Insomnia Parkinsoniansymptoms
Some types ofschizophrenia
Muteness Neurolepticmalignantsyndrome
PsychomotorretardationSuicidal ideation
Preparation for ECT• Physical exam, blood ct., chemistry,
urinalysis, & baseline memory abilities• Consent form “informed”• Eliminate benzodiazepines prior• Trained electrotherapist & anesthesiologist• Nursing responsibilities
– NPO 8 hours prior to ECT– Atropine 1 hr. prior to treatment– Have patient urinate before treatment– Remove hairpins & dentures– Take vital signs– Reduce anxiety--be positive
Procedures During ECT
• IV inserted• Electrodes placed on
head• Bite-block inserted• Brevital IV• Anective IV,
neuromuscular blocking agent
• Ventilate 100% O2
• Electrical impulse 150 volts, 0.5 - 2 sec.
• Monitor, heart rate, rhythm,BP, EEG
Nursing Care After ECT
• Ventilate with 100% O2 until breathing unassisted
• Monitor for respiratory problems• Reorient patient, time, place, person• If agitation may need benzodiazepine• Constant observation• Document all aspects of treatment• Monitor seizure activity, EEG
Contraindications for ECT
• Very High Risk– Recent myocardial
infarction– Recent CVA– Intracranial mass
lesion
No absolutes
• High Risk– Angina pectoris– Congestive heart
failure– Extremely loose teeth– Severe pulmonary
disease– Severe osteoporosis– Major bone fractures– Glaucoma– Retinal detachment– Thrombophlebitis– Pregnancy– Use of MAOIs– Use of clozapine
Disadvantages ECT• Temporary relief• Memory impairment,
before and after ECT• Physiological effects
– hypertension– arrhythmias– alterations in cardiac
output– hemodynamic changes– increases in
myocardial o2 consumption-ischemia
– seizures
Other Somatic Therapies
• Psychosurgery• Insulin-Coma• Metrazol-induced convulsions
Psychosurgery• Types
– Cingulotomy– Subcaudate tractotomy– Capsulotomy
• Outcomes, psychosurgeries– Suicide rate of 1300 persons dropped 15% to 1% post op
• Contraindications– <20 yrs or >65 yrs– brain pathology, atrophy or tumor– personality disorders: borderline, paranoid, antisocial,
histrionic– substance abuse
• Adverse Reactions– Altered personality– infection, hemorrhage, hemiplegia,seizures, suicide, wt.
gain
Phototherapy: Seasonal Affective Disorder
• Light box• Phototherapy
visor• Head-mounted
light unit• Dawn stimulator