NUR1230 Dementia/ Depressive Disorders

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NUR1230 Dementia/ Depressive Disorders
2014-09-13 09:25:05
Dementia Depressive Disorders NUR1230

Dementia/ Depressive Disorders
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  1. cognition (Wahrnehmung/ Erkenntnis)

    can be affected by many variables like:
    • sensory impairment
    • physiologic health
    • environment
    • psychosocial influences
    • (smoke does not improve cognition, mood r decrease strees in older adults ;)  )
  2. intelligence reg. older adults
    • -progressive decline beginning in midlife
    • environment and health have strong influence

    spatial perception (raeumliche wahrnehmung) and retention of nonintellectual information decline

    problem solving, math, verbal comprehension do not decline

    positive effects reg. intelligence from cardiovascular health, stimulating environment, high levels of education, occupational status, income
  3. Learning and memory
    significant declines in intelligence and learning are evitable (vermeidbar)

    high education, good sensory function, good nutrition, need for problem solving skills, ...

    in general decline in fluid intelligence: biological determined intelligence used for flexibility in thinking aand problem solving

    no decline in crystallized intelligence: gained through education + lifelong experience, verbal skills stay intact

    ->> termed classic aging pattern of intelligence

    important for learning: good health and motivation
  4. How can a nurse support the process of learning among older adults?
    • supply mnemonics (Eselsbruecken) to enhance recall of related data
    • encourage ongoing learning
    • link new with familiar information
    • use visual, auditory and other sensory cues
    • encourage prescription glasses and hearing aids
    • glare free lighting
    • quiet environment
    • short term goals
    • teaching periods short
    • pace learning speed accord. to learner
    • encourage verbal participation
    • reinforce successful learning positively
  5. Mental health problems in the older adults
    • changes in
    • cognitive ability
    • excessive forgetfulness
    • mood swings
    • are NOT part of normal aging

    do not dismiss these symptoms-> thorough assessment may reveal treatable phys. /mental condition
  6. What can cause changes in mental status?
    • alterations in diet
    • fluid and electrolyte balance
    • fever
    • low oxygen level (cardiovascular or pulmonary disease?)
  7. depression- behavior, appearance
    • persistently sad
    • dejected appearance
    • psychomotor agitation and/or retardation
    • decreased sex. interest
    • "I don't care nay more"
    • difficulty with even simple tasks
  8. depression-mood and emotions
    • verbalizes feelings of sadness and depression
    • inability to enjoy activities which were enjoyed
    • low self-esteem
    • feeling ineffective, worthless, inadequate
    • pessimistic
    • anxiety, panic attacks, irritability, anger
    • ambivalence: feel two  opposing ways at the same time
  9. depression-thoughts, beliefs, perceptions
    • thoughts slowed
    • poor concentration, possible temporary impairment of recent memory,
    • loss of perspective
    • guilt
    • narrowing of interest to self
    • suicidal thoughts
    • confusion
    • delusions, hallucination
    • life has no meaning
    • there is no future
  10. depression-relationships and interactions
    • withdrawal
    • deterioration (Rueckgang) because of preoccupation with self , anger anxiety
    • increasing dependence on others because of inability to make decision or care for self
  11. depression-physical responses
    • lethargy, fatigue, especially in the morning
    • constipation

    • decreased/increased appetite
    • sleep problems incl early morning awakening, frequent awakening, sleeping all the time , feeling tired
    • body aches, headahes, indigestion, dizziness
  12. depression- pertinent (passende) history
    • past history of depression
    • family history of depression
    • history of substance abuse
    • history of stroke, myocardial infarction (high rate of depression)
  13. depression- pharmacological
    • recommended moderate to severe depression: first line treatment (SSRIs) Selective Serotonin Reuptake Inhibitors and newer atypical antidepressants
    • differences among meds
    • side effects, rate of onset, drug-drug , variables in patient profile, ...
    • 3-4 weeks of use before full benefit
    • often relief in other symptoms before subjective improvement realized
    • side effects must be monitored closely
    • MAOI's Monoamine oxidase inhibitors are used less but may be a 2nd or 3rd line of treatment

    • severe motor-retardation -. may be stimulant like methylphenidate (Ritalin) of modafinil (Provigil)
    • herbal products like stimulants ma huang (contains ephedra)  Gingko biloba, SAM-e,most common John's wort (can interact with some HIV meds with inhibiting action)
  14. depression-psychotherapy
    • important component of treatment
    • combination therapy with meds
    • short theraphy: cognitive -> improving treatment adherence
    • -> direct treatment to alter negative thoughts
    • group therapy also good for socialization
  15. depression-electroconvulsive therapy
    • ECT is a first line treatment onlu for patients with more severe or psychotic forms
    • might also be used for those who have failed to respond to other therapies
    • or for those that cannot take meds
  16. nursing management
    depression- self care deficit
    • evidenced by decreased ability to manage own hygiene, grooming,...
    • patient outcomes
    • increased participation in self care
    • daily activities...
    • Interventions:
    • determine patients level of self-care before onset of depressive symptoms to set realistic goals

    • observe patient also when thinks being unwatched...
    • encourage as much independency as possible
    • assign care to staff that is patient/has more time
    • create positive attitude
    • small meals high inn protein and nutrition dense
    • break down tasks into small steps
    • ease patients participation
    • reassurance and encouragement
    • patient might increase amount of own decisions

  17. nursing management
    depression self-esteem disturbance
    • evidenced by statements of low self-esteem, misinterpreting positive or pleasurable experiences,
    • expression of shame or guilt,
    • thoughts of worthlessness, failures
    • negative reinforcement
  18. depression- when to call for help
    • severe self-care deficit to point of not being able to care for basic needs
    • suicidal thoughts, threats, attempts
    • hallucinations or delusions
    • severe side effects from antidepressants including severe urinary retention dramatic fluctuation of blood pressure cardiac complications, seizures
  19. depression- who to call for help
    • psychiatric team,
    • social worker
    • attending physician
  20. agnosia
    loss of ability to recognize objects
  21. agraphia
    difficulty writing and drawing
  22. alzheimer's disease
    • progressive deterioration (Verfall) of memory and intellectual functioning
    • often leading to complete loss of functioning and personality
    • brain atrophy (Schwund), senile plaques, neurofibrillary tangles (Durcheinander)
  23. apraxia
    inability to carry out motor activities despite intact motor function
  24. delirium
    rapid fluctuation of mental status, memory deficits, disorientation, perceptual disturbances over a short period of time
  25. dementia
    multiple cognitive deficits: aphasia, apraxia, agnosia, disturbance in executive function..
  26. mixed dementia
    vascular dementia and alzheimer's disease simultaneously
  27. interventions with patients with dementia
    look directly at patient, always tell own and others namesmall sentences, easy wordsdocument which easy words workif patient keeps repeating a question (could be a sign of anxiety-> reassure that patient is cared for if words not understood, focus on patient's feelings possibly being communicatedremain calm with inappropriate behavioravoid arguing or trying to convince patient that he'/she is overreactingfamily/caregiver support
  28. possible nursing-Dx with patients with dementia
    • impaired memory ( AEB confusion, ...r/t ...)
    • risk for injury (AEB falls
    • confusion, acute
    • confusion, chronic
    • family processes, interrupted
    • sensory perception, disturbed
    • sleep pattern, disturbed
    • therapeutic regimen management: ineffective
    • thought processes, disturbed
  29. When to call for help with delirium/ dementia
    • sudden onset of confusion
    • episodes of patient becomming physically combative
    • patient becomes danger to self or others because of poor judgement (driving,...)
    • severe agitation (aufregung) unresponsive to meds or other interventions
    • delirium that does not remit (nachlassen) or gets worse
  30. who to call for help with patient with delirium/dementia
    • social worker
    • security
    • psychiatric team
    • geriatrician
  31. drugs that commonly cause delirium include:
    • anticholinergics
    • benzodiazepines
    • steroids
    • antiemetics
    • opioids

    possible side effect is orthostatic hypotension, so closely monitor BP
  32. commonly used meds for confused patients are also:
    • short acting benzodiazepines
    • SSRI's (selective serotonin reuptake inhibitors)
    • Buspirone (busbar)-> several weeks to
    • anticonvulsants (for rage)
  33. medication to slow down disease process alzheimer
    • hydrochloride (Aricept)
    • rivastignine (Exelon)
    • Galantamine (Rozadyne)
    • Memantine (Namenda)
  34. Medication:

    Trade: Ativan (Lorazepam)
    most frequently prescribed ...xx
    xx =Benzodiazepine: -pam

    • used for: anxiety, anxiety with depression
    • seizures and status epilepticus, anticonvulsant (entkrampfung)
    • alcohol withdrawal, preoperative medication,

    action of anxiolytics resembles the action of sedative-hypnotics

    longterm use is discouraged, tolerance within weeks or months
  35. there are 2 types of anxiety
    primary anxiety: not caused by medical condition or drug use

    secondary anxiety: related to selected drug use, medical or psychiatric disorders

    anxiolytics are usually not give for secondary anxiety, unless medical condition is untreatable, severe, and causes disability
  36. symptoms of severe anxiety attacks
    • dyspnea (difficulty breathing)
    • choking
    • chest pain
    • heart palpitations (Herzklopfen/-rasen)
    • dizziness
    • faintness
    • sweating
    • trembling
    • shaking
    • fear of losing control
  37. nonpharmacologic measures for decreasing anxiety
    relaxation techniques, psychotherapy, support groups,...
  38. Benzodiazepines
    • readily absorbed by GI tract
    • primarily metabolized by the liver and extreted in urine -> lower dosage for patients with renal and/or liverdisease
    • controlled substance, can be seen in urine weeks or months after last usage

    • herbal alert: kava kava should not be combined with benzodiazepines -> increase in sedative effect
    • halflife 10-20 hours
    • acts on CNS
    • onset 15-30 min. PO, -> peak 2hours
    • 1-5 min. IV,->longest duration of action = 1h
    • duration: 12-24h
    • do not take for longer than 3-4 months -> effectiveness lessens after that (tolerance)
  39. anxiolytic

    Buspirone hydrochloride (BuSpar)
    limit intake of grapefruit juice to 8 ounces daily / half a grapefruit to avoid toxicity interaction
  40. Assessment before administration of Benzodiazepines
    • allergy
    • CNS depression
    • shock, coma, seizures
    • liver/ renal impairment
    • alcohol intoxication
    • pregnancy
    • lactation
    • suicidal ideation
    • history of anxiety reaction
    • patient's support system
    • drug history
    • drug drug interactions? report if possible

    inhibiting GABA neurotransmission
  41. Benzodiazepine antagonist
    flumazenil (Romazicon)

    Used to partially or completely reverse benzodiazepine dose fron sedation, anesthesia, and overdose.

    Not to be used together with antipsychotics and antidepressants
  42. Nursing interventions when giving benzodiazepine
    • observe patient for side effects
    • recognize tolerance and dependency can occur
    • dosages for older adults, kids and debilitated persons should be lower
    • monitor vital signs
    • esp. BP and pulse
    • orthostatic hypotension might occur
    • educate patient and family
    • encourage family to be supportive of patient
  43. patient teaching with benzodiazepine
    • no driving or other dangerous equipment
    • no alcohol with drug
    • control excess stress and anxiety (relaxation techniques...)
    • effective response may take 1-2 weeks
    • encourage to follow drug regimen, not to withdraw abruptly
    • teach patient to stand up slowly

    evaluate drug effectiveness/ outcome
  44. side effects of benzodiazepine
    • sedation
    • dizziness
    • headache
    • dry mouth
    • blurred vision
    • rare urinary incontinence
    • constipation
    • leukopenia (decreased WBC count) with symptoms of fever
    • malaise
    • sore throat
  45. suggested treatment for overdose benzodiazepine
    • emetic (Brechmittel) or gastric lavage (Spuelung)
    • administer antagonist flumazenil (Romazicon) IV if required
    • maintain an airway, gove oxygen, monitor vitalsigns
    • Give IV vasopressors for severe hypotension
    • request mental health consultation for patient
  46. Antidepressantsare divided into five groups:
    • (1) tricyclic antidepressants (TCAs), or
    • tricyclics;
    • (2) selective serotonin reuptake inhibitors (SSRIs);
    • (3) selective
    • norepinephrine reuptake inhibitors (SNRIs); (4) atypical antidepressants that
    • affect various neurotransmitters, and
    • (5) monoamine oxidase inhibitors (MAOIs).
  47. TCA's
    tricyclic antidepressants
    • TCAs
    • are used to treat major depression.

    • The action of TCAs is to block the uptake
    • of the neurotransmitters norepinephrine and serotonin in the brain.

    The clinical response of TCAs occurs after 2 to 4 weeks of drug therapy.

    • The TCAs have many side effects: orthostatic
    • hypotension, sedation, anticholinergic effects, cardiac toxicity, and seizures.

    • Most TCAs can cause blood dyscrasias
    • (leukopenia, thrombocytopenia, and agranulocytosis) requiring close monitoring
    • of blood cell counts
  48. SSRIs

    most common one: fluoxetine (Prozac)

    • block the reuptake of serotonin into the nerve terminal of the CNS, thereby
    • enhancing its transmission at the serotonergic synapse.

    • The primary use of SSRIs
    • is for major depressive disorders.

    • They are also effective for treating anxiety
    • disorders such as obsessive-compulsive disorder, panic, phobias, posttraumatic
    • stress disorder, and other forms of anxiety.
    • Many SSRIs have an interaction with grapefruit juice that can lead to possible
    • toxicity.

    • Fluoxetine
    • (prototype drug) produces common side effects such as dry mouth, blurred
    • vision, insomnia, headache, nervousness, anorexia, nausea, diarrhea, and
    • suicidal ideation. Some patients may experience sexual dysfunction when taking
    • SSRIs.

    Do not consume more then 1/2 grapefruit per day when taking this drug.
  49. Contraindications SSRI's
    • do not take together with MAOIs
    • dehydration
    • breastfeeding
    • acute myocardial infarction
    • severe depression with suicidal tendency
    • severe kidney or liver disease, glaucoma, seizure disorder, diabetis mellitus underweight
  50. action SSRI
    serotonin is increased in nerve cells because of blockage from nerve fibers