neurocognitive disorders

barriers to care for older adults

stereotypes about aging

seeing mental illness as a weakness, more stigmatizing

seeking help may be seen as a loss of control

fear of institutionalization

skepticism about mental health professionals

healthcare professionals not specialized in geriatric care

limited resources

mental health disorders in older adults

anxiety

phobias

OCD

depression

mania

somatic symptoms

schizophrenia

alcoholism

depression in older adults

depression and anxiety are most prevalent in older adults

presentation: memory disturbances, somatic complaints

“having the blues”

misdiagnosed as dementia d/t shared s/s

r/f suicide in older adults

older adults are more likely to die by suicide

white men over 65 have the highest rate

chronic suicide- uses slower, less obvious means; refusing food, excessive alcohol, inconsistent med use

associated with feelings of burdensomeness or loneliness

predictors: older than 65, male, white, chronic or uncontrolled pain, bereavement, unmarried, social isolation, retirement, financial issues, ETOH/drug abuse, hx of previous attempt, MDD

special considerations for older adults

many age related changes can impact mental health

dependence, relocation, isolation, financial hardship

certain losses occur more frequently in the geriatric population

loss of health, loved ones, hearing and vision, status, work, income, cognitive skills, home, community, mobility

communication with older adults

do not rush; allow time to answer

avoid interruptions

establish rapport: handshake, eye contact, title and surname

face pt and articulate clearly

provide hearing aids or glasses

minimize glare or noise

privacy

match pt vocab level

psychotropic drug use guidelines for older adults

start low, go slow- one third to one half adult dose; gradual increase

simplify dosing schedule

consider effects of other drugs, conditions

discontinuation- taper off meds

psychosocial assessment of older adults

accommodate unique needs

be aware of anxiety

may be reluctant to discuss problems with a stranger or younger person

irritation with direct questions- use open ended questions

use strategies to give them a sense of control and increased self esteem; positive reinforcement

nonjudgmental

listen to pt stories- conveys acceptance and appreciation, allows pt to convey important information

assess themes- guilt, stress, grief, fear, despair

ascertain past coping strategies, strengths, weaknesses

include caregivers to clarify or expand

assess ability and willingness of caregivers to provide care for pt

physical assessment of older adults

are these s/s of mental disorder r/t physical illness

assess for s/s of abuse or neglect

determine how physical problems interfere with ADLs

guide selection of interventions and services to meet identified needs

older adults milieu and enviornment

furniture- promotes mobility and socialization

large print books and games

personal items in room for orientation cues

respect privacy

minimize precipitating factors for aggression

manage environmental stimuli

redirection

provide activities to foster independence

high contrast, vivid colors

non slip floors

non glare lighting

furniture heights, arm rests

handrails

shower stools, grab bars

pictures, universal symbols

comfortable air temp and safe water temp

neurocognitive disorders

characterized by deterioration of cognitive functioning

some cases may be temporary

common impairments: memory, orientation, attention, decision making, emotions, language, motor skills

divided into 2 types: delirium and dementia

delirium

acute fluctuation in attention, cognition, and awareness

caused by medical condition, meds, substance use, etc

acute onset

other signs: fluctuating LOC, slurred speech, disorientation, confusion

reversible once cause is identified and treated- medical illness associated

nurse must ensure safety- hydration, access to assistive devices, ambulation, sleep, social engagement

dementia

umbrella term

slow deterioration of cognitive abilities

no cure, but meds may help

alzheimer’s disease: 60-80% of those dx with a neurocognitive disorder

alzheimer’s disease

most common cause of dementia

prevalent memory loss and cognitive impairments

ADLs first affected

plaques and tangles- hallmark signs of disease

insidious onset, gradual progression

dx by specialists- MMSE, MOCA

alzheimer’s global deterioration scale

stage 1- no cognitive decline; no problems in daily living

stage 2- very mild cognitive decline; forgets names and locations of objects, trouble finding words

stage 3- mild cognitive decline; difficulty traveling to new locations and handling problems at work

stage 4- moderate cognitive decline; difficulty with complex tasks (finances, shopping, planning for guests)

stage 5- moderately severe cognitive decline; needs help to chose clothing, needs prompting to bathe

stage 6- severe cognitive decline; needs help putting on clothing, requires assistance bathing and may be scared, decreased ability to use toilet or is incontinent

stage 7- very severe cognitive decline; limited vocab, eventually no or only single words are spoken, loses ability to walk and sit, unable to smile

stages 1-3 are pre dementia; 4-7 are dementia

progression through these stages varies; could take years

causes of alzheimer’s

multiple etiologies

amyloid and tau proteins form plaques and tangles

neuronal loss- brain atrophy; in advanced disease brain may weight less than half of a normal brain

genetics

hormones

behavioral changes in alzheimer’s disease

memory loss- short term first, long term remains at first

developmental regression

word finding difficulty

difficulty concentrating

misinterpreting the enviornment

delusions

illusions

somatic preoccupations

misidentification

sundowning

loss of ability to care for self

drugs for alzheimer’s disease

6 meds are FDA approved

cholinesterase or acetylcholinesterase inhibitors- tacrine (not used in US), donepezil (aricept), rivastigmine (exelon), galantamine (razdyne)

memantine (namenda)

only subtle improvements

no evidence that they slow or prevent disease process

other neurocognitive disorders

vascular disease

frontotemporal disease

parkinson disease

lewy bodies

due to TBI

prion disease

HIV

ETOH induced

huntington disease

psychotherapeutic management

nurse client relationship- validation techniques

communication

scheduling

nutrition

toileting

wandering

psychopharmacology

psychotropics may be indicated for aggression

low dose

nonpharmacological interventions first always

milieu management for neurocognitive disorders

room temp and lighting to pt preference

reduce noise

purposeful TV/media use

match roommate personalities

memory aids- calendars, notes, directions, pillboxes

caregivers and alzheimer’s disease

advanced directive

family caregivers make sacrifices to keep pt at home

need education and support

advanced technologies/aggressive medical care has poor outcomes

palliative care- emphasis on comfort

prolonged grief

antidementia drugs

categorized into drugs for tx and drugs for prevention

used to improve symptoms or reduce/delay burden

cholinesterase inhibitors

donepezil (aricept)

• half life 60-90 hours

• max plasma concentration in 3-5 hours

• fewer peripheral side effects

• advantages- no hepatotoxicity, once daily, 100% bioavailability with or without food

rivastigmine (exelon)

• half life 2 hours

• not metabolized by CYP-450

memantine (namenda)

NMDA

long half life: 60-80 hours

approved for moderate to severe AD

often combined with donepezil or other ChE inhibitors