Safety and Cognition, Delirium, Alzheimers, and Depression Meds (Pathopharm Exam 3 Content)

characteristics of Alzheimer's

changes in brain structures and function:

- amyloid plaques

- neurofibrillary tangles (occur inside the axon)

- loss of connections between neurons

- neuron death

*** disruption in this process can lead to neuron death

Alzheimer's - nursing care/interventions

- redirection - changing patient's focus
- reassurance - communicate to patient that they will be protected from harm
- distraction - music therapy, art therapy, etc.
- keep skin clean and dry
- change patient's position
- quiet and unhurried environment
- avoid distractions at mealtimes
- low lighting, music
- easy grip utensils
- no longer tolerating oral feedings - consider NG/PEG tubes
- infections - UTI and pneumonia most common
- caregiver support - family roles, altered/reversed, teaching guide for family

symptoms of delirium (9)

1. psychomotor agitation or impairment
2. perceptual disturbance
3. altered sleep-wake cycle
4. inattention
5. acute onset
6. altered level of consciousness
7. disorientation
8. disorganized thinking
9. memory impairment

what are the EARLY manifestations of delirium?

- inability to concentrate
- disorganized thinking
- irritability
- insomnia
- loss of appetite
- restlessness
- confusion

what are the LATE manifestations of delirium

- agitation
- misperception
- misinterpretation
- hallucinations

what is the confusion assessment method used for? how?

-used to diagnose delirium
how it works:
- 4 categories (A, B, C, D)
- need both features in cat A and B AND C and AND/OR D
- A = acute onset, fluctuating course
- B = inattention
- C = disorganized thinking
- D = altered level of consciousness
*** see slide 6 for more info!!

what are the differences between delirium and dementia?

- onset
- course
- duration
- attention
- consciousness
- reversibility
- behavior
- orientation
- memory
- perception
- speech
- thought
- sleep

what labs would you draw for infection?

- urine culture/urinalysis
- CBC
- chest x-ray
- reversible (infection, metabolic, nutritional, medication)
- rapid tests (swab nose, mouth, etc.)
- blood cultures (can get this while getting bloodwork)

what is the most common form of dementia?

Alzheimers

what is the onset of Alzheimers? course?

- onset = chronic, progressive
- course = degenerative

what neurotransmitter is low in Alzheimer's disease? what are the effects of this change in levels?

- Helps with memory (long-term, working memory) and the ability to form, store, and recall information.

- Plays a role in motivation, attention, learning, arousal, and promoting REM sleep.

- If ACH levels are low over a long time, it can contribute to Alzheimer’s disease. short-term dips in ACH is not bad

explain how acetylcholine is made?

** produced by the mitochondrion
1. ACh is made from choline and Acetyl CoA
2. in synaptic cleft, ACh is broken down by enzyme (acetylcholinerase)
- Choline is transported back into the axon terminal and is used to make more ACh

Alzheimer's diagnostics

- NO definitive test (we mostly diagnose by ruling out - aka diagnosis of exclusion)
- history and physical
- CT scan
- magnetic resonance imaging (MRI)
- positron emission tomography (PET)
- lumbar puncture
- CBC, CMP, glucose, BUN, creatinine, LFTs, thyroid function
- depression screening

what would you see on a brain scan with Alzheimer's?

atrophy of the brain

what are the different stages of Alzheimer's

- mild
- moderate
- severe

Alzheimer's - nursing considerations

- Behavioral problems: Repetitiveness, Delusions,Agitation, Aggression, Wandering, etc.
- Assess for pain, bowel, bladder, changes in Vital signs
- Assess for extreme temperatures or excessive noise
- Safety: Falling, wandering, ingesting substances, navigating spaces, feedings
- Supervision
- Assessing home environment
- Medical Alert Bracelet

what are important oral care considerations for patients with alzheimers?

- may not be able to perform self care
- may have swallowing difficulties
- dental caries and tooth abscesses (can lead to agitation)
- assess mouth and perform regular oral care

systemic syndrome characterized by decreased attention span (inattention)
- patient is unaware of disorganized thinking

delirium

what is the onset for delirium? is it reversible?

- acute = onset is mins to hours
- reversible

what are common causes of delirium (hint: remember mnemonic)

- Dementia, dehydration
- Electrolyte imbalances, emotional stress
- Lung, liver, heart, kidney, brain function
- Infection, being in ICU
- Rx (meds, drugs)
- Injury, immobility
- Untreated pain, unfamiliar environment
- Metabolic disorders

why are patients in the ICU more at risk for delirium?

- this is a specific case of delirium (ICU delirium)
- caused by the constant checks (interrupts patient's ability to sleep)
- medications
- more likely to have delirium related-conditions like heart, liver, metabolic impairment, etc.
*** we assess regularly for dementia in ICU for tis reason

wha is the treatment for delirium?

***eliminating precipitating factors (i.e. meds, electrolyte imbalances, etc.)
- correct fluid and electrolyte imbalances or nutrition deficiencies
- environment - correct over or under stimulation
- infection - identify and treat

sleep inertia

how quickly you are able to wake out of sleep
- people who are awoken abruptly may experience delirium to some extent

delirium or dementia?
- onset = abrupt or subacute
- course = fluctuates
- duration = days to weeks
- attention = impaired
- consciousness = fluctuates, impaired
- reversible
- behavior = agitated or withdrawn (change from premorbid state)
- orientation = impaired but can fluctuate
- memory = impaired (change from premorbid state) mainly due to inattentiveness
- perception = visual hallucinations predominate
- speech = incoherent
- thought = disorganized
- sleep = sleep/wake reversed or disturbed hour to hour

delirium

delirium or dementia?
- onset = insidious (meaning gradual but subtle)
- course = progressive
- duration = permanent
- attention = impaired in late stages
- consciousness = alert/stable (can be impaired in dementia with Lewy bodies and terminal stages)
- reversibility = often irreversible
- behavior = impaired in late stages (can be apathetic to agitated - depends on type)
- orientation = impaired in late stages
- memory = impaired and progressive
- perception = auditory and visual hallucinations (depends on type)
- speech = word-finding difficulty
- thought = impoverished (decreased thinking, ability to express thoughts)
- sleep = fragmented

dementia

a group of symptoms affecting memory, thinking, and social abilities, that interfere with life

dementia

what is a common cause of altered mental status that is not often treated? how would you test for this?

(any infection of the brain really)
- meningitis
- encephalitis
*** have to do a lumbar puncture to assess

what are the different types of dementia?

- Alzheimers disease
- vascular dementia
- lewy body dementia
- Parkinson's disease dementia
- Creutzfeldt- Jakob disease (a type of prion disease)
- Wernicke -Korsakoff disease (thiamine deficiency)
- reversible (infection, meds, metabolic, nutritional, etc.)

what group is more at risk for thiamine deficiency and potentially Wernicke-Korsakoff disease?

Alcoholics

Alzheimer's or dementia?
- a specific brain disease that accounts for 60-80% of dementia cases

Alzhiemer's

Alzheimer's or dementia?
- a general term for symptoms like decline in memory, reasoning, or other thinking skills

dementia

what types of meds can cause dementia-like symptoms?

statins

what demographic is more likely to develop Alzheimer's? why?

women (due to longer life span)

how does social determinants of health impact Alzheimer's?

will affect the way/access to care

what is the etiology of Alzheimer's?

- UNKNOWN etiology (combo of genetic and environmental factors)
- NOT a normal part of aging
- develop prior to 60 years old = early onset
- develop after 60 years old = late onset

type of Alzheimers disease that has a clear pattern of inheritance; associated with early onset and rapid disease progression

Familiar Alzheimer's disease (FAD)

what diet may Alzheimers patients need?

- pureed foods, thickened liquids
** due to poor swallowing and chewing

what are some elimation considerations for alzheimers patients?

- urinary and fecal incontinence may develop in later stages of disease
- may need habit/behavioral training
- may experience constipation (can be treated with stool softeners and fiber supplements)

Alzheimer's - assessments

- pain: may need to rely on other cues if unable to communicate
- skin - assess patient's skin, incontinence, immobility, and undernutrition
- infection - change in behavior, cough, fever, pain, painful urination
- assess caregiver support

what is the drug we need to know for Alzheimer's?

Donepezil (Aricept)

Donepezil (Aricept) - class

acetylcholinesterase inhibitor
- Alzheimer drugs

Donepezil (Aricept) - MOA

- patients have decreased levels of acetylcholine
- cholinergic drugs increase concentrations in the brain inhibiting cholinesterase
- increase in ACh levels helps to enhance and maintain memory and learning capabilities
- Allows Ach to have longer action on the postsynaptic receptor as a cholineterase inhibitor
- Allows thetransmission to continue to move forward

Donepezil (Aricept) - therapeutic use

- improves memory (with mild to moderate disease) by enhancing effects of Ach in neurons in cerebral cortex not yet damaged
- does NOT reverse disease

what form is Donepezil available in?

oral tablet

Donepezil (Aricept) - how is it excreted?

- excreted via kidneys

should you take Donepezil (Aricept) be taken with or without food

does NOT matter!!
***no absorption difference when taken with or without

Donepezil (Aricept) - onset of action

- should be taken for 6 months to determine benefit
- dosing may be changed at 6 weeks

Donepezil (Aricept) - goal of therapy

improved activities of daily living, behavior, and cognition

Donepezil (Aricept) - adverse effects (and how can these be avoided)

- bradycardia
- drowsiness, dizziness
- GI upset
- syncope
- insomnia
- muscle cramps
- orthostatic hypotension
*** important note: these meds exacerbate the risk for falls!!
*** can be avoided by careful dose titration

Donepezil (Aricept) - contraindications

- Known drug allergy
- GI or GU tract obstruction
- Bradycardia or defects in cardiac impulse conduction
- Hyperthyroidism
- Epilepsy
- Hypotension
- COPD
- Parkinson's disease (cautionary)

Donepezil (Aricept) - interactions

- anticholinergics
- antihistamines
- sympathomimetics
- other cholinergic drugs
- cholinergic agonists
- parasympathomimetrics

Donepezil (Aricept) - signs and symptoms of toxicity

** toxicity occurs that too much inhibition (intentional and unintentional) impulse never stops and creates manifestations
- circulatory disease
- hypotension
- SLUDGE (salivation, lacrimation, urination, diarrhea, GI distress, emesis)

Donepezil (Aricept) - antidote

Atropine

Betty Longello, 75-year-old female, fell and fractured her right hip. She had an open reduction internal fixation (ORIF) performed 8 days ago and was discharged to subacute rehab in preparation for returning home. You(the nursing student) enter her room to perform an assessment to find her half on and half off the bed. Betty is rambling about needing to get the chores done and pulling at her gown. You explain to her that you are going to help her back into bed. As you are trying to assist Betty back into bed, she becomes distracted and starts pulling at your clothing.
- What cues stand out?
- Based on the cues, what do you think is going on with the client?What assessment(s) could you complete?
- What could be the potential cause(s)? How could this be determined?
- What are the potential treatment(s)? How would the nurse evaluate the effectiveness of treatment?

- what cues stand out? - surgery postop day 8, rambling, high stress, pulling at gown, easily distracted, starts pulling at your clothes
- what's going on - may be delirium, infection, overstim, meds, etc.
- assessments: med list, cultures, CBC/blood test, neuro/cog assessment
- interventions: reassure, redirect, speak calmly, distraction
- effectiveness - patient is calm and not a harm to themselves and others

Six months ago, Mario Grant, 72-year-old was experiencing forgetfulness, especially short-term memory loss. His spouse reported that she had to take over balancing the bank accounts and had become impatient. After testing, he was diagnosed with Alzheimer's dementia and was started on Donepezil 5mg PO at bedtime. He presents to the office today for follow-up.
- What cues would indicate to the nurse that the medication is effective?
- What assessments would the nurse complete to determine if the client is experiencing any adverse effects?
- The physician decided to increase the client's dose to 10mg PO at bedtime. The spouse of the client asked how this medication works again. What do you say to her?
- What teaching would the nurse need to complete?

- what cues would indicate med is effective = forgetfulness, orientation (name, date, what time of day is it), mood, withdrawn, etc.
- assessments for toxicity = vitals, vision, hydration status, fluid intake and output
- how does med work = stops breakdown of ACh by inhibiting the enzyme (acetylcholinesterase) that breaks it down
- Teaching - watch out for falls, hypotension, lethargy, bradycardia

depression - how does it commonly occur?

- chronic physical illness and comorbitiies (increased if someone has two or more chronic health issues)
- substance use and anxiety are comorbid conditions

what are the 3 types of depression?

1. Reactive - as a result of a traumatic/depressing event
2. major - can be primary or secondary (related to other health diagnoses)
3. bipolar affective disorder - manic (euphoric) and depressive (dysphoria)

depression - causal theories

- dopamine - (alertness) working memory, motivation, clarity
- norepinephrine - (concentration) execution, perseverance, recall memory
- serotonin - (satisfaction) learning memory, pleasure/pain, relaxation
*** all three play a role in sense of wellbeing
see slide 34 for more info

what do dopamine and serotonin contribute to?

- appetite

what do dopamine and norepinephrine contribute to?

intuition

serotonin
- where it is found
- what is it associated with
- what does it help with

- derives from tryptophan, primarily in GI tract (90%), the rest is in the CNS (parasympathetic cholinergic receptors)
- associated with feelings of wellbeing, regulation of food, attention, behavior, body temp, cognitive functions of memory and learning
- assists in sleep, bone health, nausea, bowel movements, blood clotting, and mood regulation

Norepinephrine (aka noradrenaline)
- what is it?
- where is it found?
- what does it do?

- both a hormone (produced by adrenal glands) and neurotransmitter (chemical messenger that transmits signals across nerve endings in the body)
- most norepinephrine in the blood comes from nerve endings
- helps with mood and ability to concentrate
- (in combo with other hormones) help body respond to stress and exercise

dopamine
- what is it associated with?
- what roles does it play?

- associated with reward and motivation behavior and motor control
- roles = executive function, motor control, motivation, arousal, reinforcement, and reward

what major disease process is associated with low dopamine levels?

Degenerative Parkinson's disease
- caused by loss of dopamine-secreting neurons that leads to motor impairment

what happens when we increase one neurotransmitter (for example serotonin)?

the other key neurotransmitters related to depression (dopamine and norepinephrine) DEcrease

depression - signs and symptoms

- sad affect
- difficulty (too much or too little) with sleep and eating
- difficulty making decisions/choices
- hopelessness, low motivation, feeling down/"numb"
- feeling angry, irritated
- anhedonia
- muscle aches
- negative self-talk
- headaches
- difficulty concentrating, remembering
- most serious complication of depression = suicide/thoughts of self harm

anhedonia

loss of interest in things that used to bring pleasure

Fluoxetine (Prozac) - pharmalogic class and therapeutic class

- pharmalogic class: selective serotonin reuptake inhibitors (SSRI)
- therapeutic class: antidepressant

Fluoxetine (Prozac) - indications

*** PRIMARY = major depression
- bipolar
- obesity
- eating disorders
- OCD
- panic attacks
- social anxiety disorder
- PTSD
- various substance abuse problems

Fluoxetine (Prozac) - MOA

reduces reuptake of serotonin in the CNS
- Causes increased extracellular serotonin concentrations & increased serotonergic transmissions

Fluoxetine (Prozac) - dosing, onset of action

- dosing: 20 mg PO daily, may gradually increase dose after several weeks by 20 mg/day (cannot exceed 80 mg/day)
- onset: 2-4 weeks

Fluoxetine (Prozac) - pharmacodynamics

- excreted by kidneys
- strongly protein bound - cumulative drug effect is a risk with long term use

Fluoxetine (Prozac) - goal of therapy

improve mood and function

Fluoxetine (Prozac) - interactions

- drug to drug interactions
- herbs (specifically st. john's wort)
- lifestyle interactions

Fluoxetine (Prozac) - adverse effects

- Agitation
- Dizziness
- Drowsiness
- Sexual dysfunction
- Headache
- Gi disturbance
- Change in weight
- Prolonged QT interval (on heart EKG)
- increased risk for suicidality

Fluoxetine (Prozac) - contraindications

- known drug allergy
- use of monoamine oxidase inhibitors (MAOIs) in previous days
- certain antipsychotics - Thioridazine or Mesoridazine
- Bupropion (in cases of seizure disorders)

excessive accumulation of serotonin in the body

serotonin syndrome

serotonin syndrome - symptoms

*** remember SHIVERS
- Shivering
- Hyperreflexia and myoclonus muscle contractions that are not voluntarily initiated - can look like spasms)
- Increased temperature (greater than 41 C)
- Vital sign instability (increased HR and RR, decreased BP)
- Encephalopathy (altered LOC)
- Restlessness
- Sweating

serotonin syndrome - nursing care/interventions

- immediate discontinuance of the medication - usually resolves the syndrome
- supportive care: hydration, antipyretics, cooling blankets
- severe cases require medical support - manage BP, provide sedation with Benzodiazepines

SSRIs withdrawal syndrome

- use of SSRIs leads to physiologic addiction - this is why abrupt discontinuation is contraindicated

SSRIs withdrawal syndrome - dosing considerations, symptoms

- dosing considerations = not meant for long-term use, must be weaned slowly to minimize risk of withdrawal
- s/s: remember FINISH
Flulike symptoms
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal

differences between infection and SSRI withdrawal

- seizures WITH fever
shvering
*** KNOW THE ANTIDOTE

what is the antidote for SSRIs?

Cyproheptadine

Tara Knauff, 28-year-old female, presents with chief complaint of loss of appetite, fatigue which is making her feel like sleeping all the time, with headaches. Upon further questioning, Tara shares that she is feeling hopeless and has lost enjoyment and motivation. The physician ordersFluoxetine 20mg daily.
- What cues stand out?
- Based on the cues, why was the medication ordered?
- What additional assessments would the nurse want to perform before the client starts the medication?
- How would the nurse evaluate the effectiveness of treatment?
- What teaching would the nurse want to include about this medication?

- what cues stand out - loss of appetite, sleeping all the time, hopeless, anhedonia, headaches (underlying neuro conditions), age, medications (high suicide risk)
- why med? - seems like depression
- assessments: depression screening (won't be tested on this - but the headaches should also be assessed via neuro assessments to ensure the etiology is not cognitive/neuro-related)
- Evaluation - patient experience healthy stabilization of emotions and is able to continue living life/completing tasks, sleeping well
- Teaching - watch for signs of toxicity, may need to followup with therapy to promote care of psychosocial aspect of depression