Psych Exam 3 Elder

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Psych Exam 3 Elder
2011-04-01 14:09:34
Nursing Psych

Mental Illness and the Older Adult and Dementia v. Delirium
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  1. Discuss the Older Adult: Complicated Mental Health Problem
    • Co-morbidities
    • Other Sx mask psychiatric d/o
    • More likely to report physical sx before psychiatric sx
  2. List Mental Health Problems in Older Adults
    • Sleep
    • Anxiety
    • Somatoform (psychiatric d/o with physical sx)
    • Thought
    • Substance Use
    • Cognitive
    • Mood/ Major Depression/ Suicide
  3. Define Paraphrenia
    • Late onset (after 65 years)
    • Dellusional d/o
    • Persucatory dellusions and schizo
  4. Discuss Polypharmacy
    • Don't tell their physican about non-prescription drugs
    • Inc depression and dec quality of life (pt perception of too many drugs)
    • 10 meds... 100% chance of drug-drug interaction
  5. Discuss ECT
    • Avoids polypharmacy
    • Effective for depression
    • Safe
    • Reccommended for Elderly
  6. Discuss Use of Psychotropic meds in Older Adults
    • Start w/ low dose
    • Predisposed to more adverse drug rxns
    • Benzos have long half-life, not appropriate
    • Account or 85% of pt falls
  7. Discuss Acetylcholine and aging
    • Acetylcholine is responsible for memory and dec w/ age
    • Meds with acetylcholine may cause: acute cognitive impairment, confusion, chronic cognitive defects
    • ACE inhibitors dec effectiveness of enzyme breaking down acetylcholine
  8. List Anticholinergic Meds
    • Tricycline Antidepressants
    • Paxil
    • GI anti-spasmodics
    • First gen antipsychotics
    • Lithium
    • Antihistamines
    • Anti-Parkinsonian
    • Muscle relaxants
    • Zantac
    • Calcium channel blockers
    • SSRIs help depression b/c they dec anticholinergic effects
  9. List Assess for Psychological Changes
    Cognitive fxn intactRxn time slowsLearning is importantMemory loss is not part of agingGerotranscendence: continued growth in dimensions such as spirtuality and inner strengthRelationship strains
  10. Discuss Assess for Social Changes
    • Functional status may decrease
    • Retirement: most are successful
    • Cultural impact
    • Social activities change
    • Community strains: Residential care, Assisted living
  11. Discuss Social Role Transitions
    • Changes in family roles: loss of spouse, poverty, sexuality
    • Retirement: Affects social roles, income, use of health services, and participation in leisure
    • Widowed women more impacted
    • Restrictions from health conditions
  12. Discuss Social Support
    • In 2 wks: have others said they care about you, have you provided help to others
    • Could you call on someone if needed
    • Besides children, do you have family you talk to 1x/mo
  13. Discuss Biologic Domain Assessment
    • Dec renal clearance
    • Dec blood flow to liver
    • Neuronal cell loss
    • Sexuality maintained (check adverse effects of psychotropic meds)
  14. Discuss Assess for Normative Biologic Changes
    • Changes in organs
    • Slow neurologic
    • Brain changes
    • Neuroplasticity- less able to make new pathways
    • All 5 senses decline w/ age
  15. Discuss Cognitive Development Changes
    • Dev task of adjusting to changes
    • Growth in spirituality, generativity, and inner strength
  16. List Risk Factors for Geriatric Psychopathology
    • Chronic illnesses: Arthritis, hypertension, heart disease, respiratory disorders, substance abuse
    • Polypharmacy
    • Bereavement and loss
    • Poverty
    • Lack of social support
    • Psychiatric Disorders: Depression
    • Shared living arrangements and
    • elder mistreatment
  17. Discuss Prevention of Mental Illness
    • Reduce stigma
    • Access to services
    • Monitor meds SE to inc adherence
    • Avoid premature institutionalization
    • Prevent depression and suicide- counseling
  18. Discuss Promotion of Mental Health
    • Social support
    • Lifestyle support
    • Self-care
    • Spiritual support
    • Community services
  19. Define Cognitive Mental Disorders
    • A disruption or deficit in cognitive function
    • Affecting orientation, attention, memory, vocabulary, calculation ability, and abstract thinking
    • APA defines 3 distinct categories:
    • 1. Delerium, dementia, and amnestic disorders
    • 2. Mental disorders resulting from a general medical condition.
    • 3. Substance –related disorders
  20. Define Delirium
    • Acute cognitive impairment with rapid onset caused by medical condition
    • Ex- “ICU psychosis”; Acute Brain Syndrome (ABS); Acute confusion; Acute psychosis
  21. Define Dementia
    • Chronic cognitive impairment
    • Differentiated by cause, not symptoms
  22. Discuss Risk Factors of Delirium
    • Children: can be related to medications or fever
    • Elderly: most commonly occurs in
    • this population group, often mistaken for dementia- (caregiver prejudice)
  23. List Delirium Etiology: Identified causes
    • Medications
    • Infections
    • Fluid and electrolyte imbalances
    • Hypoxia/ischemia
  24. Discuss Delirium Etiology: Variety of brain alterations
    • Reduction in cerebral functioning
    • Damage to enzyme systems, blood–brain barrier, or cell membranes
    • Reduced brain metabolism
    • Imbalance of neurotransmitters
    • Raised plasma cortisol level
  25. List 3 Main Features of Delirium
    • 1. Cognitive changes with rapid onset(several scales i.e. MMSE) disordered cognition
    • 2. attention deficit: difficulty focusing, sustaining, or shifting attention
    • 3. disturbed Consciousness: reduced level of consciousness
    • May be disoriented to time and place, but rarely to person
    • *Develops over a short period of time
    • Usually reversible if underlying medical cause is identified
    • Serious, should be treated as an emergency
  26. List Behavior Change of Delirium
    • –Hyperkinetic delirium
    • Psychomotor hyperactivity
    • Excitability
    • Hallucinations
    • –Hypokinetic delirium
    • Lethargic
    • Somnolent
    • Apathetic
  27. List 3 Classic Autonomic Responses
  28. Discuss Biologic Assessment of Delirium
    • Id nml
    • Health status
    • Physical exam and Sx
    • Labs
    • Physical fxn
    • Substance abuse hx
    • Rx Meds and OTC
  29. List Nsg Diagnoses for Delirium
    • Acute confusion
    • Disturbed thought processes
    • Disturbed sensory perception
    • Hyperthermia
    • Acute pain
    • Risk for infection
    • Disturbed sleep pattern
    • Interrupted family processes
    • Ineffective protection
    • Ineffective role performance
    • Risk for injury
  30. List Nsg Interventions for Delirium
    • Safety- from self
    • r/o life-threatening illness
    • stop suspected meds
    • monitor VS, behavior, mental status
    • correct underlying cause
    • supportive measures- hydrate, pain
  31. List Pharmacologic Interventions for Delirium
    • Antipsychotics
    • Atypical antipsychotics (cardiac SE)
    • Benzos (use before antip for hepatic problems)
    • Manage SE
  32. Discuss Restraints
    • Avoid
    • Unless pt in danger to self or others
    • Inc agitation- causes rhabdomyolysis
  33. Discuss Psychological Interventions of Delirium
    • Frequent brief interaction
    • Support for confusion or hallucinations
    • Encouraged to express fears and discomforts
    • Adequate lighting
    • Easy-to-read calendars and clocks
    • Reasonable noise level: decrease stimulation
    • Frequent verbal orientation
    • Devices available: eyeglasses and hearing aids
    • Comfort measures to instill trust
  34. Discuss Evaluation of Delirium
    • Correction of underlying physiologic alteration
    • Resolution of confusion
    • Family member verbalization of understanding
    • Prevention of injury
  35. List Sx of Delirium
    • Sudden onset
    • Fluctuating course
    • dec consciousness
    • dec attention
    • dec cognition
    • Hallucinations
    • dec activity ( hypokinetic v. hyperkinetic delirium)
    • Incoherent speech
    • Involuntary motor movement
    • Illness, toxicity
  36. List Sx of Dementia
    • Insidious onset
    • Stable course
    • Clear
    • dec cognition
    • Hallucinations may be present
    • Activity baseline Normal
    • Speech baseline Normal
    • Normal motor movement
    • No underlying illness or abnormal lab findings
    • depends on stage of illness
  37. List Etiology of Dementia
    • Beta-amyloid plaques
    • Neurofibrillary tangles
    • Cell death and neurotransmitters
    • Genetic factors
    • Oxidative stress and free radicals
    • Inflammation
  38. Discuss DSM IV for Dementia
    • A syndrome with cognitive deficits resulting from a general medical condition, use of a substance, or multiple biologic etiologies. ..severe enough to compromise social or occupational function, and decline from previous functioning.
    • All forms affect memory and cognition
    • Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death
  39. Discuss Diagnosing Dementia
    • Essential feature: multiple cognitive deficits
    • One or more of the following:
    • Aphasia (alterations in language)
    • Apraxia (impaired ability to execute movement)
    • Agnosia (failure to recognize or identify objects)
    • Disturbance of executive functioning- i.e. making decisions
  40. Differentiate 2 Types of Alzheimers
    • Early-onset (65 years and younger) Rapid progression
    • Late-onset (over 65)
  41. Discuss Mild Dementia
    Forgetfulness, misplace articles, decreased recall, social withdrawal, frustrated with self, changes may not be apparent to others
  42. Discuss Moderate Dementia
    decreased ability for self-care; way-finding; disoriented to time and place; wandering, pacing, possible hallucinations or delusions begin, decreased visual perception leading to accidents; needs supervision; emotional lability-big swings; symptoms noticeable
  43. Discuss Severe Dementia
    cannot care for self; loss use of language; minimal long term memory; constant complete care
  44. List Priority Care Issues of Dementia
    • Priorities will change throughout the course of the disorder
    • Initially, delay cognitive decline
    • Moderate level: protect patient from hurting self
    • Late stages: physical needs become the focus of care
  45. Discuss Biologic Assessment of Dementia
    • Health Status
    • Physical Exam
    • Physical Fxns: self-care, sleep-wake disturbance, activity and exercise, nutrition, pain
  46. Discuss Psychological Assessment of Dementia
    • Responses to mental health problems: personality changes
    • Cognitive status (MMSE and others)
    • Memory
    • Language
    • Visuospatial impairment
    • Executive functioning
  47. List Psychotic Sx of Dementia
    • Suspiciousness, delusions, and illusions
    • Hallucinations
    • Mood changes
    • Anxiety
    • Catastrophic reactions
  48. List Behavioral Responses of Dementia
    • Apathy and withdrawal
    • Restlessness, agitation, and aggression
    • Aberrant motor behavior
    • Disinhibition
    • Hypersexuality
    • Stress and coping skills
  49. Discuss Social Domain Assessment of Dementia
    • Functional status, social systems, spiritual assessment, legal status, and quality of life
    • Extent of primary caregiver’s personal, informal, and formal support systems
  50. Discuss Interdisciplinary Tx of Dementia
    • Confirm Dx
    • Establish baseline
    • Therapeutic relationship
    • Tx efforts: mgt of cognitive sx, delay in cognitive decline, tx of noncognitive sx, support caregiver
  51. Discuss Biologic Intervention of Dementia
    • Self-care
    • Nutiriton
    • Support elimination
    • Sleep
    • Activity and exercise
    • Pain and comfort
    • Relaxation
  52. Discuss Pharmacologic Interventions of Dementia
    • ACE Inhibitors
    • Antipsychotics
    • SSRIs
    • Anti-anxiety (caution)
    • Avoid meds with Anticholinergic effects
  53. List Psychological Interventions of Dementia
    • Cognitive Impairment
    • Psychosis
    • Alterations in Mood
  54. List Social Interventions of Dementia
    • Patient safety interventions adjusted for progression through stages of dementia
    • Environmental interventions
    • Socialization activities
    • Home visits
    • Community actions
  55. List Other Interventions for Confusion
    • Speak clearly, slowly, directly
    • Don’t approach from behind
    • Face patient
    • Use of para-verbal and nonverbal communication techniques
  56. List Other Dementias
    • Vascular dementia
    • Dementia caused by other conditions:
    • AIDS
    • Head trauma
    • Parkinson’s disease
    • Huntington’s disease
    • Pick’s disease
    • Creutzfeldt-Jakob disease
    • Substance-induced persisting dementia
  57. Discuss Amnestic Disorder
    • Impairment in memory caused by medical condition or persisting effects of a substance
    • Severe memory impairment without other significant cognitive symptoms
    • Can be caused by a variety of pathologic processes