lec 10: dementia, delirium, depression

what is cognitive function

complicated process by which an individual perceives, registers, stores, retrieves, and uses information

body and mind are inseparable

most elders will not suffer significant impairment

what physical illnesses are associated with cognitive impairment

stroke, heart disease

parkinson's disease, Alzheimer's

endocrine disorders

cancers (tumors), epilepsy (seizures)

B12 deficiencies

chronic pain, viral illnesses, lengthy hospitalization

why is heart disease associated with cognitive impairment

can impact cognitive statues d/t impaired/slower blood flow, which can increase confusion

why is parkinson's disease associated with cognitive impairment

d/t protein deposits that develop

why are endocrine disorders associated with cognitive impairment

individual with diabetes; high serum blood glucose and glucose is what feeds the brain → cellular starvation can lead to confusion/coma

why are lengthy hospitalization associated with cognitive impairment

can cause hospital delirium for being in the same room for many days

what psychosocial factors are associated with cognitive impairment

serious losses (loss of spouse)

difficult relationships

changes in social roles (having children as caregiver)

loneliness, poverty

unplanned moves/forced relocation

medication side effects

depression

what is dementia

chronic, progressive (does not get better), insidious (slow), and permanent states of cognitive impairment, terminal

what is delirium

an acute and sudden impairment of cognition that may be considered temporary

what is depression

found/characterized by low mood, difficulty thinking, somatic changes

can be a precursor to dementia

what is the biggest risk factors for alzheimer's disease

age

why is the cost increasing for alzheimer's and other dementia

money is going to dementia units, home care, nurses, aids, research for meds, insurances; treatment/medication/pharmaceuticals

medication is EXPENSIVE!

what are the different stages of alzheimer's disease

stage 1 - normal adult

stage 2 - normal older adult

stage 3 - compatible with early AD

stage 4 - mild AD

stage 5 - moderate AD

stage 6 - moderately severe AD

stage 7 - severe AD

what is stage 1 of alzheimer's

no impairment - normal individuals

what is stage 2 (normal older adults) of alzheimer's

self report of memory impairment, no objective cognitive impairments are noted

ï forgot my keys,” "where is the remote” ; normal people forgetfulness

what is stage 3 (compatible with early AD) of alzheimer's

cognitive impairments recognized by other anxiety; impaired performance in demanding work and social settings

• stage where AD is usually diagnosed

• very sad stage and people realize something is wrong → people get scared/anxious

• when others realize it's not just forgetfulness 

• lot of trouble completing tasks when working, trouble multitasking, trouble speaking and calling 

  • cannot order/speak the words that you want

what is stage 4 (mild AD) of alzheimer's

withdrawal, denial, depression, inability to perform ADLs and complex tasks, flattening of affect, cognitive impairment evident on exam

• see lot of withdrawal, stay at home, do not want to meet friends or go out, embarrassed, in denial that they do not have disease  

• trouble buttoning shirt 

• mini mental test (is performed in suspicion of alzheimer's disease); screening tool 

  • ask questions about "count backwards from 20 on every 3rd number"

what is stage 5 (moderate AD) of alzheimer’s

disoriented to time and place; needs assistance in clothing selection

• ex. geriatric patients at nursing homes

what is stage 6 (moderately severe AD) of alzheimer's

forgets name of spouse and other family members

personality and emotional changes

• residents will be crying, mood swings, angry, depressed 

• ex. individual dress up in heels and stockings, wears a dress, put on lipstick, mop the floor → when you get alzheimer's someone can refused to wear a bra; if was forced to wear a bra will rip it up and flush it down the toilet 

inability to perform many ADLs → agitation

what is stage 7 (severe AD) of alzheimer's

loss of verbal and psychomotor skills; incontinence; needs total assistance

• total care geriatirc patients

• do everything for them and continue to deteriorate 

• will probably get pneumonia, UTI, and patient gets weaker and weaker → eventually pass away

what is vascular dementia

thought to be caused by cardiovascular factors → MI, strokes

heart attack/stroke affect circulation to brain

what is lewy body dementia

most common after Alzheimer's

similar to parkinson's disease, protein deposits

what is frontotemporal lobe (other types of dementia)

personality changes & atrophy of frontal lobe; athletes with head injuries

need to rule out delirium because symptoms can be very similar (such as agitation)

what is AIDS dementia

just like other organs the brain can deteriorate

what is trauma's relationship with other types of dementia

falls, MVA, head injuries is significant cause of dementia

what is needed to diagnose dementia

symptoms and clinical diagnosis

what are symptoms of dementia

short term and long term memory impairment

• will have good long term memory for the first few stages of dementia

  • where they met their spouse, who their parents are, where they grew up

what are clinical diagnosis of dementia

loss of intellectual ability with impairment severe enough to interfere with social or occupational functioning

delirium has been ruled out

not able to work, drive, ADL, socialize (will not remember people)

what test should be done to diagnose dementia

CBC → to rule out infection

TSH → to rule out depression; if depressed = thyroid count is affected

Basic metabolic panel and LFT-DM, drugs, alcohol?

• liver function test

vitamin B12 deficiency → can cause confusion and memory loss

MRI or CT → rule out masses, lesions, tumors?

what is the primary intervention when caring for patient with dementia

symptomatic nursing care

• it is a life limiting and chronic illness

• caregivers require training and expertise → long term and end of life care

• family caregivers also require supportive care → respite

person with dementia develop

challenging behavioral and psychiatric symptoms

• alleviate symptoms

  • teach patients and caregivers about the effects of dementia → promote + reduce feelings of distress

what do nurses need to do for people with dementia and their families

promote independence and autonomy

prevent avoidable complications → UTI, falls, pressure ulcers, malnutrition

promote quality of life

how to support the family of a dementia patient

assistance and support is important to families and is an integral part of nursing care

do NOT assume that the family understands basic care techniques

• need to teach family how to bathe patient, interact with them, how to reposition, how to put a brief on 

• if you know a patient drinks better w/ a straw and you see the family trying to give patient a drink, get them a straw!

what should nurses review with families when caring for dementia client

basic care such as lifting, bathing, managing inappropriate behaviors

what type of emotions do caregivers of clients with dementia feel

nurses should prepare family for the guilt, frustration, anger, depression, and other feelings that accompany the responsibility of a caregiver

what should the nurse advise caregivers taking care of dementia family member

assist family with obtaining respite care → when things are overwhelming in the home and the caregiver needs a break. Patient can go to nursing home or centers (go for a week or so to give the family a break)

encourage the family to network with support groups and obtain counseling as needed

how to make a safe environment for dementia patients

modify strategies used to prevent injuries to toddlers to provide a safer physical environment for older adults with dementia

• use baby monitors, put mattress on the floor

tour home with caregiver to identify safety issues and develop a safe plan

summary for nurses role with dementia patients

we can help elderly with dementia to live full, dignified lives by showing patience, compassion, and understanding

what is the etiology of delirium

disturbances in neurotransmission in the brain which control cognition, behavior, and mood

cholinergic failure

poor cerebral blood flow

complication of illness

drugs or substance effect on brain

general anesthesia → can remain longer in body in older adults; do not want to perform surgeries on elderly because it can cause delirium

why is it difficult detecting delirium

often seen as confusion

• confusion is abnormal in youth and middle aged adults but is sometimes seen as normal in the elderly

delirium over dementia is difficult to determine

medical emergency

causes acute, distress, sometimes fearful

what are potential causes

infections

CNS masses - neoplasms, subdural hematomas

medications

dehydration

what are nursing interventions to prevent delirium

orientation and therapeutic activities for cognitive impairment

early mobilization to avert immobilization

non-pharmacologic approaches to minimize the use of psychoactive drugs

interventions to prevent sleep deprivation

communication methods and adaptive equipment (vision and hearing impairments)

early intervention for fluid volume depletion → dehydration can cause delirium

how do we orient and what are therapeutic activities to prevent delirium

use calendar, clock (let them know what date and time); use menu (things simple and easy to explain)

what are non-pharmacologic approaches to prevent delirium

put on happy music, happy visuals, activities, open blinds take them outside so that wind is blowing on their face and touch grass

what are interventions to prevent sleep deprivation to prevent delirium

minimize napping time

take them outside

OOB and into chair

having them around other people during the day

how to get resident good sleep> → lights off, TV off, glass of warm milk

what are communication methods and adaptive environment to prevent delirium

make sure patient has their glasses / hearing aid with them otherwise it can lead to delirium bc they’re confused

what are consequences of delirium

significant distress

high morbidity during hospitalization → unattended can get out of control

functional decline

post op complications

increased length of stay

low rate of recovery to prior level of functioning → each episode of delirium leads to a decline in functioning

institutionalization

what are the two types of delirium

hypoactive vs hyperactive

patient is not acting like themselves

what is hypoactive delirium

patient normally very active and became

• quiet, pleasantly confused, lethargic, withdrawn, limited/slow and wavering vocalizations

what is hyperactive delirium

patient normally calm/kind/quiet become

• heightened alertness, easily distracted, hallucinations, delusions, agitated, aggressive, fast/loud speech, wandering, repetitive movements, removing tubes, attempting to get out of bed

what are nursing interventions for patients with delirium

re assess cognition using established tools

be sure basic needs are met

review medications

understand behavior, determine root cause

maintain safety with minimal use of restraints (do everything before using restraints)

lessen invasive procedures

modify the environments

family involvement

what are established tool to assess cognition in patients with delirium

mini cognitive assessment → ask them to repeat 3 words

ask name, time, place

why do we review medications for patients with delirium

new medication can be causing this temporary state

what are the rules/policy when using restraints

oder for restraint requires 2 physician orders

remove every hours to assess skin and give break

how do we modify environment for patient with delirium

make sure it’s safe.

morning = open blinds. night = close blind and quiet

why do we involve family with patients with delirium

what works for them

bring in only a few (maybe 1) family member that they’re close to that they find soothing

what are common events requiring psychological adjustments

widowhood

confronting negative attitudes of aging → scared/afraid of aging

retirement → feel like there's no purpose in life or feel they do not contribute to society

chronic illness

functional impairments

decisions about driving a car

death of friend/family

relocation from home to assisted living → all the memories of you home and now gone

(the longer the person lives, the more likely events will occur that require coping and adaptation)

what are risk factors for high levels of stress and poor coping

diminished economic resources

immature development level

unanticipated events → death of a spouse

many daily hassles at the same time in one day

many major life events occurring in a short period of time → all your friends dying at the same time

unrealistic appraisals of situations

what is depression associated with

stroke, heart disease

parkinson's disease, Alzheimer's

endocrine disorders

cancers (tumors), epilepsy (seizures)

B12 deficiencies

chronic pain, viral illnesses, lengthy hospitalization

(same as dementia)

what can cause depression

difficult relationships

changes in societal roles

retirement

widowhood

loneliness, poverty

unplanned moves

medication side effects

age related changes

how can depression risk be decreased (nonpharmacological intervention)

Light therapy for seasonal affective disorder (SAD)

Electroconvulsive therapy (ECT)

Psychotherapy

how can depression risk be decreased (pharmacological interventions)

antidepressant, mood stabilizers, antianxiety drugs

need to be very careful with these drugs because in elderly the body slows down and drugs stay longer in system

what are nursing interventions

assist older persons in identifying stressors and rating their levels of stress

help the older person identify successful coping mechanisms used in the past

assist the older person in examining current coping mechanisms and behaviors

alter or eliminate negative or maladaptive mechanisms

investigate community resources, support groups, stress-reduction clinics, and other stress relievers

encouraging appropriate self-care behaviors

how do we promote healthy aging, social interaction, and problem solving

travel with senior citizens groups

outside activities

taking classes

elder hostels

volunteer work

regular exercise

hobbies and crafts

increased family involvement