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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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 stimulus..like 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)
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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-
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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dementia the three A
memory
- 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
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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
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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
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Protective factors: dementia
- mediterranean diet
- incre education
- incre mental activity- doing things like a cross word puzzles
- increa physical activity
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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)
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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
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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
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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)
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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)
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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
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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
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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
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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
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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
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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
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MMSE IV
- IV recall
- ask them to recall the three words. check the box to the right with each response
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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
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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
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geriatrics depression scale
look at slides to get an idea
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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
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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
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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
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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
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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
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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
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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
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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
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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 happens...talk about something else. speak one person at a time
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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
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other communication strageties
look at slide
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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
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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
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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
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caretakers strain intervention
look at slide
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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
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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
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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
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Flurizan
- new drug
- slows down the formation of plaques in the brain
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