care of the patient with a cognitive disorder

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  1. What is cognition?
    • highest level of brain activity
    • cognition is the act or process of thinking, perceiving, learning
    • cognition function effected by delirium or dementia include:
    • - decision making
    • - problem solving
    • - reasoning
    • - judgment
    • - memory, spatial orientation- knowing r hand from L hand. this becomes a problem. also being able to transition from one activity to another. pt w/cognitive disorder..this becomes a problem.
    • - thinking, reasoning
    • - verbal communication- language
    • how do we think how do process information. how does brain transfer information thru neurons.
  2. Normal age related memory loss
    • sometimes loses things, familiar items
    • briefly forget a friend's name
    • sometimes needs to search for words
    • occasionally forgets to complete task
    • forgets the distant (remote) past
    • momentarily gets lost
    • jokes about memory loss
  3. Cognitive disorder abnormal
    • biologic illnesses with two defining characteristics:
    • 1. decrease in cognitive function
    • 2. Organic etiology (physical underlying problem. organic (physical) problem)
    • Cognitive impairment:
    • - brain chemistry and function changes (neurotransmitters serotonin if they are wack then the brain activity can slow or speed up)
    • - structure, neurons lost and brain unable to compensate for the losses- brain cells begin to die  (dementia)
    • - not normal part of aging
    • - > 50% not identified
    • dementia- there are physical structure changes
    •  it be caused by
    • - polypharmacy- med interaction could cause confusion
    • - toxins, chemicals
    • - structural changes can cause confusion
  4. Three D's of cognitive impairment: Geriatrics syndrome
    • 3 D's cognitive impairment are:
    • - delirium
    • - dementia
    • - depression
    • - all have similarities and differences. can occur any age (addiction to hallucinagenics drugs it could cause brain changes that are irreversible)
    • frequently affect older adults.
    • frequently affect older adults
    • pathological progression require urgent
    • assessment and intervention
    • - any changes in mental status
    • can come on suddenly or slowly
    • urgency to catch this
  5. Delirium
    • direct physiological consequence of medical condition: syndrome not disease
    • - transient cognitive impairment- fluctuates comes and goes
    • rapid/abrupt onset- suddenly
    • - acute or sub acute (Potentially reversible to accurate diagnosis is needed if u take the underlying problem she can return back to normal)
    • - improve if person doesn't die
    • underlying med/physical issue
    • contents of thought is dyfunctional
    • transition (environment to environment) can cause confusion
    • anesthesia can cause confusion
    • assessment is key- catch early and deal with it so it doesn't cause more damage
    • UTI- confused
  6. risk factor for delirium Box 21-1
    • polypharmacy- esp polypharmacy of high dose psychotrophic drugs, high doses of hypnotics, drug toxicity
    • hospitalization or post surgery
    • multiple co morbid condition- severe infections, CV disease, COPD
    • poor nutritional status
    • hepatic failure
    • chronic renal failure
  7. Delirium - etiology
    • CNS: head trauma, epilepsy, brain tumor
    • Vascular: stroke, hypertensive encephalopathy
    • metabolic: renal/hepatic disease, fluid/electrolyte imbalance, hypoxia
    • cardiopulmonary: congestive heart failure, shock arrhythmias
    • systemic: septicemia, UTI, pnemonia, neoplasms
  8. more etiology for delirium
    • sensory deprivation: postoperative state, visual/hearing impairment
    • substance induced: intoxication or withdrawal
    • medications: antichol, antihistamine, antiarhythmics, sedatives, narcotics analgesics, histamine 2- receptor blocker, anticonvulsants, beta blockers, antihypertensives, corticosteriods, antibiotics
    • toxins- chemicals etc
  9. Delirium can include
    • Delirium is prevelant disorder and can include:
    • - children who swallow poisons/have high fever
    • - adolescents and adults who abuse drugs
    • - elders hospitalized for surgeries or who have dementia
    • - elders hospitalized for acute physical illnesses and then develop delirium range from 14-80%
    • - patients with delirium while hospitalized have longer hospital stays, high rates of nursing home admissions, experience greater decline in function
    • cost of caring for patients with delirium is increased because of the demanding need for continous intervention from staff caregivers
  10. Signs and symptoms of delirium (defining characteristics)
    • occurs over a short period of time, LOC fluctuates, no set patterns
    • ability to focus is greatly impaired, easily distracted
    • impaired memory- recent memory (why they are in the hosp what did they have for breakfast)
    • disorientation and confusion
    • misinterpretation, illusions (misinterpretation of looking a cord on the floor and thinking it was a snake), hallunicinations (abnormal response to anything that can effect the senses: visual, hearing, smell, touch)
  11. S/s delirium cont
    • behavioral disturbances: continual aimless activity- pulling the blanket up and then pulling it down
    • labile (rapidly changing) mood- rapid, unpredictable changes- mood can turn on a dime. u could be helping them and then all of sudden they start pushing you away
    • sleep pattern disturbances-
  12. Considerations in Assessment
    • poor performance on memory tests cause anxiety- can be worst or judgemental.. reorient them without making them feel bad
    • perform assessments with hearing aids and glasses as needed
    • environment needs to be free from distractions
    • timing is important (do not rush) should not be completed:
    • - immediately upon wakening
    • - right before/after meals or procedures
  13. patient comprehensive evaluation and assessment
    • Physiologic assessment is based on the following workup
    • - hx of physical examination
    • - vital signs- includes and o2 stat
    • - medication and substance use abuse hx
    • - neurological examination- r/o stroke, cranial, nerve, tone of muscle
    • - neuropsychological exam- mental status- mini cog status
    • - MSE (mental status evaluation)
  14. Patient comprehensive evaluation
    • Labs: crucial, CBC, eletrolytes, LFT (new med could challenge the liver, you are looking for amonia level), thyroid, BUN, creatinine, VDRL (syphyllis), urinalysis, urine culture and sensitivity, drug screens
    • CT scan, MRI and ECG
    • functional assessment, geriatric depression (scale to r/o depression)
    • EEG
  15. Course of the illness
    • reversible in over 80% of the cases
    • onset usually rapid, course fluctuates
    • may be super imposed on other disorders
    • difficult to identify because of fluctuating nature
    • when unrecognized, patients can suffer irreversible brain damage
    • early recognition is key in the prevention and treatment
  16. Implication for nursing
    • early recognition is early
    • Assessment:
    • - MSE: establish baseline
    • - don't assume what you see is there baseline: interview caregivers and families
    • - ongoing monitoring
    • Tools objective, avoid "confusion":
    • - MMSE
    • - CAM- confusion assessment method
    • - NEECHAM confusion scale
    • - CAM- ICU (bc of the noise no transition from night to day)
    • acute confusional state (NANDA)
    • once u realize u change the meds...dose...u can give them K
    • it could be dehydration- hydrate them
  17. delirum treatment
    • Indentify underlying cause and treat
    • - d/c or decrease meds if cause
    • HELP- (hospital Elder life program) focuses on managing 6 risk factors for delirium:
    • - cognitive impairment
    • - sleep deprivation
    • - immobility
    • - visual/impairments
    • - dehydration- can lead to delirium- look at skin turgor
  18. Nursing intervention by risk factors delirium
    • 1. cognitive impairment:
    • - reorientation
    • - attention to patient concerns and fears
    • - reassure family transient
    • - delay medical nursing procedure until daylight
    • - sedation for agitation, restlessness, risk to self (atypical antipsychotic- low dose, monitor closely, dc asap)
    • Fall risk reduction- bed alarms, low bed recliners, keep routines as normal as possible
    • sitters
  19. Continue nursing intervention by risk factor delirium 2-6
    • 2. sleep deprivation
    • - herbal tea, milk v. sleep meds
    • - quiet environment
    • 3. immobility
    • - remove catheters/other devices that interfere with movement, avoid restraints
    • 4/5. visual/hearing impairments
    • - glasses/hearing impairments, speak slowly make eye contact, use familiar words and repeat when necessary
    • 6. dehydration
    • - fluids, electrolytes, nutrition, vitamins, o2
  20. Take away points to remember...delirium
    • delirium, an acute change in cognition and attention, is common, morbid and costly
    • in the inpatient setting, all new changes in mental status should be assumed to be delirium until otherwise
    • elements of the hospital environment can contribbute to delirium and expose pts to safety risk
    • family members and caregivers are crucial to diagnosis and management of delirium; incorporating them into the plan of care is strongly recommended
  21. Dementia
    • Def: chronic loss of previously acquired mental function due to loss of brain cells
    • interferes with ability to think, perceive and reason
    • develops over a slow period of time
    • is a progressive and degenerative central nervous system disorder
  22. dementia the three A
    • detoriation of mental (neurologic) function- Memory
    • - memory loss
    • - disorientation
    • - difficulty learning
    • - loss of language skills (asphasia)
    • - decrease judgement and planning
    • - can have perceptual and psychoses
    • - personality changes, emotional labile
    • 1. apraxia- inability to carry out motor activity
    • 2. agnosia- failure to recognize object
    • 3. aphasia- language disturbance (can use the muscles that help them speak...u know the word but u can't say it)
    • impairment in social or occupational functioning
    • VS normal
    • progressive over the yrs irreversible
    • 8-10 yrs- onset to death usually dies from complications from organ
  23. Incidence dementia
    • most disabling and burdensome of chronic conditions in older adults
    • estimated 5.4 million
    • African American 2x more likely as whites, hispanics 1.5x more likely
    • increased in the past few decades
    • - incre awareness
    • - more acute diagnosis
    • - incre longevity creating larger population of elderly
    • 3x cost medically than those without disease
  24. Risk factors: Dementia
    • Age, eye, and ear problems
    • family hx
    • genetics- more likely to develop:
    • - apoE4-apollpoprotein, causes cell death, memory loss and neurological dysfunction
    • head trauma, tumor
    • systolic hypertension
    • down's syndrome
    • untreated infectious/metabolic/endocrine disease
    • substance abuse/mental illness
    • female gender
    • lesser yrs of education- don't continually using your brain cells
  25. Protective factors: dementia
    • mediterranean diet
    • incre education
    • incre mental activity- doing things like a cross word puzzles
    • increa physical activity
  26. Types of Dementias
    • alzheimer's # 1
    • vascular dementia #2 (3), multi infarct, post stroke
    • diffuse lewy body disease #3 (2)
    • parkinson's dementia
    • mixed dementia
    • Less commonly occuring:
    • - frontotemporal/picks disease
    • - creutzfeldt jakob disease
    • - down syndrome dementia
    • - neurosyphillis dementia
    • - normal- pressure hydrocephalus
    • - ALS (amyotrophic lateral sclerosis= lou gelrig's disease)
  27. Irreversible dementias
    • alzheimer disease- causes 50-70% of cases of dementia. it is the most common form of dementia. it is a degenerative neurological disorder
    • there is progressive deterioration of areas in the brain essential learning and memory (cortex) caused by lesion:
    • - neuritic plagues and neurofibrillary tangles destroy nerve cells
    • - degeneration (forebrain) diminishes
    • acetylcholine (some meds now that will slow down the progression of disease), neurotransmitter that conducts impulses between neutrons
  28. Dementia: S&S
    • insidious, gradual onset (months), mild severe fluctuations
    • long duration of symptoms
    • normal level of conscious: alert, aware, attentive, BUT altered content (disorientation)
    • VS normal typically
    • multiple cognitive deficits, especially memory impairment and one or more of the following: aphasia, agnosia, apraxia, impaired executive functioning
  29. S&S dementias cont
    • hallmark symptom as with delirium is memory impairment- short term first, inability to learn new material/recall previously learned /both
    • memory impairment progresses to other intellectual abilities: speech, reading, writing, comprehension, difficulty finding words
    • aphasia- deficits in language
    • apraxia- problems with motor activities
    • agosia- difficulties with object identification (usually common household items)
  30. more s&s  cont
    behavior changes: sleeplessness, sundowning (incre behavioral difficulties in the evening), catastrophic reactions (overexaggerated emotional responses initiated as a result of a perceived failure at a task or change in the environment), wandering, agitation, combativeness, perserveration (excessive repetition)
  31. Physiologic assessment: rule out reversible cause (of delirium)
    • Physiologic Assessment is based on the following workup including laboratory data:
    • - urinalysis
    • - CBC
    • - serum vitamin b12 level
    • - metabolic screen: serum electrolytes with mg and LFT
    • - TSH
    • - VDRL
    • - HIV
    • - lyme titer
    • - urine toxicology screen
  32. neuroimaging helpful in identification of diagnoses
    causing s&s of dementia or delirium
    • recent head trauma
    • hx of CVA or vascular disease
    • tumors
    • abscesses
    • subdural hematoma
    • seizure disorder
    • some PET scans being done, showing shrinkage of hippocampis: decre glucose metabolic activity
  33. Cognitive assessment tools
    • look at slide
    • purpose: to assess orientation, intellectual functioning, memory, reading and math skills and identify specific stages of dementia
    • mental status screening
  34. MMSE: Mini-Mental Status Exam
    • I orientation:
    • what is today
    • what is the year
    • what is the month
    • can u tell me the season
    • can u tell me the name of the hospital
    • what floor are we on
    • what town/city
    • what county are we in
    • what province are we in
  35. MMSE II
    • II immediate recall
    • this is to test their memory
    • three unrelated items ie ball, flag, tree
    • have them repeat back...if they get wrong do it up to 6 times
    • number all the trials
  36. MMSE III
    • III attention and calculation
    • counting backward by 7 start with 100. check each response in the box to the right
    • spelling backward test
    • like world
  37. MMSE IV
    • IV recall
    • ask them to recall the three words. check the box to the right with each response
  38. MMSE Language V
    • Naming- show them an object and let them tell u what it is
    • Repetition- ask them No, ifs, ands, or buts
    • Three stage command- esta which hand they write with...take paper, fold it in half and put in on the floor..they should follow commands
  39. MMSE reading, writing, copying VI
    IV reading:hold up and paper and have something written on it...ask them to read and do it ie close your eyes

    writing- ask to write sentence. it should contain a subject and a verb

    copying- show picture of intersecting pentagons..have them copying..ignore tremors and rotations
  40. geriatrics depression scale
    look at slides to get an idea
  41. ADL scale
    • based on six things
    • bathing, dressing, toileting, transferring in and out of bed and chair
    • urine and bowel incontinence
    • eating
    • each criteria is graded on level of indepence:
    • - performs independently
    • - performs with assistance
    • - unable to perform
    • independent- suggest a score of 0-1
    • dependent- approaches 6
  42. Instrumental ADL
    • indications
    • assess functional capabilities of older patients
    • survey
    • based on 7 things
    • - telephone (look up numbers dial and answer)
    • - traveling via car public transportation
    • - food or clothing shopping
    • - meal prep
    • - housework
    • - management of medication
    • - managing money
    • graded in three parts
    • independent
    • assistance needed
    • dependent
    • two separate surveys completed
    • pt
    • informant- nurse, caregiver, family
  43. Info on dementia
    • onset slow, insidious, progressive, and terminal
    • usual 8-10 yr of onset of symptoms death
    • some can live up to 15 yr
    • it will lengthen continually
    • cost- 80-100 billion annually
  44. Alzheimer's stage 1: mild
    • 1-2 yr
    • recent memory impairment: neologisms common pt complains of forgetfulness, covers up, called confabulation, blames accuses others, transitory delusions of persecution
    • disorientation about time people and place usually remains in tact initially
    • cognitive losses in communication- difficulty in noisy, distracting environment, judgement impaired, errors in judgemental accident
    • losses in calculating, unable to balance check book
    • acts confused, becomes irritable and quiet. emotionally inability common
    • personal apprearance may decline needs help in selecting appropriate clothing
    • sensory and muschle functions still in tact except muscle can be hypertonic/twiching
    • self awareness- recognize their own confusion, covers this up, frightened. leads to depression-worsens symptoms of dementia
    • begins to have problems and work family school
  45. Alzheimers Stage 2: moderate
    • several yrs. cognitive decline decre, amnesia, disoriented all three spheres, apraxia, agnosia, aphasia, misidentification syndrome (familiar people are seen as unfamiliar vice versa), perservation
    • poor impulse control/outburst/tantrums emotionally labile
    • behavior problems:
    • - catastrophic reactions
    • - wandering/pacing
    • - sundowning- sleep cycle impaired
    • poor jugdement
    • sleep disturbance
  46. Alzheimers stage 3: severe
    • loss of meaningful communication- may lose all speech, perservate/echo sounds
    • emotional response dwindle to nonresponsive
    • total dependence on caregiver
    • incontinence
    • secondary illness related to immobility-motor skills seriously deteriorated, cannot walk sit smile bedridden
  47. Nanda-
  48. Primary Patient outcomes
    • absence from risk of harm to self or others
    • reach and maintain the highest functional level possible
    • maintain the best possible physical status
    • be free from catastrophic reactions
    • participate in therapeutic activity program for cognitive stimulation and socialization
  49. primary caretaker outcomes
    • knowledge of dementia
    • uses positive interaction with pt
    • plans for develops resources/respite services
    • appro legal and financial plans in place for self and pt
    • back up in case of emergency
  50. Nursing intervention dementia
    • reassure
    • caring relationship, unconditional positive regard
    • - positive therapeutic reaction- patience
    • respect personal space- dont touch
    • redirect: less demanding activity- modify environment stable provide as much control as possible
    • observe and evaluate verbal/non verbal responses
    • identify triggers and indicators of anxiety
    • evaluate care routine and responses q 24 hr
    • leave alone if unable to stop/decrease reaction
    • - act like nothing about something else. speak one person at a time
  51. intervetion dementia continue
    • give realistic positive feedback- praise success
    • watch time, maybe easy fatigue, have short attention span
    • encourage pt to use skills, promote indepence
    • do not ask pt to participate in ADLs when agigated
    • structured routines, simple choices, simple verbal msgs, 5-6 words, repeat in necessary, flexibility
  52. other communication strageties
    look at slide
  53. wandering
    • may be r/t visuspatial impairments, anxiety, depression,poor sleep patterns, unmet needs, more socially active & outgoing premorbid lifestyle
    • safety concerns
    • affects sleep, eating, caregiver's ability to provide care interes with privacy of others
    • stimulus may be internal and external
    • can be predicted thru observation knowing patterns
  54. wandering reduce risk interventions
    • alarms bells on windows and door
    • keyed locks, child door lock
    • lock windows
    • label all rooms
    • disconnect garage door
    • hats, purse, keys- items associated with leaving home
    • fence in good repair/gates locked
    • dont leave home alone
    • hide car keys disconnect battery
    • ID braceltes
    • ask neighbors to call if they see them
    • have photos and identifying data on hand
    • provide for exercise
    • safe return program thru alze assoc
    • for the rest look at slide
  55. catastrophic reactions: an extremely intense emotional reaction to a small event
    • what was the person doing prior
    • trying to understand > 1 direction at a time
    • new environment/staff
    • minor accident
    • make judgement. multitask
    • negative interaction- being scolded, arguement
    • experiencing hallucination, delusions, illusions
  56. caretakers strain intervention
    look at slide
  57. cholinesterase inhibitors
    • neurotransmitter that aids in transferring information into meaning (memory and thinking)
    • the process of this disease breaks down acychl
    • the brain makes less and less use (why memory and abilty to think thru things is diminished)
    • meds stop acychol from breaking down- it delays the the memory loss, delays the progression of symptoms. not a cure. just slows it down
  58. F
  59. FDA cholinesterase
    • Aricept: donepezil, second generation
    • - better tolerated longer half life
    • s/s GI N/D, insomonia, musc cramps
    • Exelon- rivastigmine
    • -gi n/v anorexia agitation, urination incre
    • - patch consistent dosing
    • Reinyl- razadyne has improved ADL
    • fewer side effects
  60. NMDA receptor antagonist
    moderate to severe impairment
    • regulates the activity of glumate- which is a chemical messenger involved in information processing, storage, and retrieval
    • too much glumate causes brain cell death
    • Namenda- Memantine 2003
    • SE dizziness, confusion, constipation, headache,skin rash (not for peeps with renal impairment)
    • less common- HTN, fatigue hallucination SOB
  61. Flurizan
    • new drug
    • slows down the formation of plaques in the brain
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care of the patient with a cognitive disorder
2015-06-09 03:01:22

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