MH-Somatic Symptom & Cognitive Disorders

What is Somatization?

Unconscious expression of psychological distress into physical manifestations; symptoms suggest medical illness but cannot be explained by underlying pathology​

What are Somatic Symptoms Disorders characterized by?

preoccupation with worrying about their physical manifestations to the point where it assumes a central role

What is Primary Gain in a somatic symptom disorder?

Main goal; relief of the unconscious psychological distress

What is a Secondary Gain in a somatic symptom disorder?

Unintended gain; Rewards obtained from the physical symptoms that might otherwise not be received

What are some General Characteristics of Somatic Symptoms Disorders?

• Often seen in medical versus mental health settings; difficulty accepting a psychological diagnosis​

• Usually chronic or recurrent​

• Tend to go from one provider or clinic to another; may be angry at medical community​

• Anxiety and depression are common comorbidities​

• Several possible etiologies and risk factors​

• Psychosocial and biologic theories​

• Typically, more common in women than men​

What is a Somatic Symptom Disorder?

• Characterized by multiple, often vague or exaggerated physical complaints/symptoms​

  • May involve any body system, often more than one (e.g., GI, neurologic, cardiopulmonary, reproductive, pain); may be acute but often chronic with periods of remission and exacerbation​

  • Contributes to significant distress and anxiety about health​

  • Interferes with daily functioning​

  • Symptoms not under patient’s voluntary control​

  • Seek care from multiple providers (“doctor shopping”) – usually seen initially in medical or primary care settings​

  • Often reject psychological diagnosis as the cause

What is Pain Disorder?

• Pain is primary physical symptom; generally unrelieved by analgesics​

• Greatly affected by psychological factors

What is Illness Anxiety Disorder?

• Belief in/fear of having (disease conviction) or developing (disease phobia) a serious disease, including misinterpretation of physical signs as “proof” of the disease, despite negative findings and clinician reassurances; very high anxiety; obsessive thoughts and fears about illness​

  • e.g., having a minor rash but insisting one has lupus​

• Chronic and relapsing condition​

• May seek care from multiple providers or avoid seeking health care

• More focused on the fear of having or developing a specific illness versus focusing on multiple, vague, exaggerated symptoms (as with Somatic Symptom Disorder).

What is Functional Neurological Symptoms Disorder?

• Characterized by transferring mental conflict into a physical symptom for which there is no organic cause​

• Symptoms: usually sudden deficits in voluntary motor or sensory functions (e.g., blindness, paralysis, seizures, hearing loss, gait disorders)​

  • Not under patient’s voluntary control​

• May cause anxiety but often exhibit la belle indifference ​

• Usually short duration; rarely chronic

What is Malingering?

• ​Intentional production of false or grossly exaggerated physical or psychological symptoms​

• No real physical symptoms, OR grossly exaggerate minor symptoms​

• Motivated by external incentives/secondary gains; able to stop the symptoms as soon as secondary gain received

• Example: avoid work; evade criminal prosecution; obtain financial compensation; obtain drugs; avoid being discharged

What is Factitious Disorder?

• Characterized by somatization in which the person intentionally causes (i.e., “fakes”) an illness or exaggerates symptoms for the purpose of assuming “sick person” role or to be viewed as a ‘hero’​

• Willfully controls the physical symptoms (not unconscious)​

• Uses various methods (some extreme) to create symptoms​

What is the goal of care for Somatic Symptom & related Disorders?

• Help the patient manage or diminish physical symptoms (not “cure” them); improve quality of life​

• It is important to recognize somatization and manage it appropriately. Failure to do so can lead to frustrating, costly, and potentially dangerous tests, treatment, and surgical interventions as well as more distress for the patient

What Nursing Interventions can be used for Somatic Symptom & related Disorders?

• Health Teaching​

  • Establish a daily routine, adequate nutrition and sleep​

• Expression of Emotional Feelings​

  • Recognize relationship between stress and physical symptoms​

  • Keep a journal​

  • Limit time spent on physical symptoms​

  • Limit primary and secondary gains​

• Teach Coping Strategies​

  • Relaxation techniques, deep breathing, distraction, problem-solving, role-playing​

What are Neurocognitive Disorders (NCDs)?

• Disruption or impairment of higher-level functions of brain (cognitive abilities/functioning)​

• Signs and symptoms often mimic other mental illnesses​

• Difficult to obtain direct evidence for a definitive diagnosis

What is Delirium?

• A syndrome that involves a disturbance of consciousness accompanied by a change of cognition

• usually reversible if it is diagnosed and treated promptly

What are some common causes of Delirium?

• Most frequent in older adults​

• Medications (e.g., drug intoxication)​

• Substance use or withdrawal​

• Infections (e.g., sepsis, UTI, pneumonia)​

• Fluid and electrolyte imbalances; nutritional deficiencies​

• Hypoxia or ischemia

• Metabolic disturbances​

• Brain tumor or head injury​

• Surgery​

• Change in environment (e.g., Hospitalization/ICU)​

• Restraint use​

• Terminally ill

What is the Goal of treatment for Delirium?

Minimize risk factors in order to prevent delirium AND identify underlying cause

What are some General Interventions for Delirium?

• Assesses and Reassessment​

• Eliminate or correct underlying cause​

• Provide a safe environment​

• Coordinate interdisciplinary treatment​

• Provide symptomatic and supportive measures

What are some Biological interventions for Delirium?

• Stop suspected medications​

• Monitor changes ​

• Maintain fluid and hydration​

• Promote sleep and nutrition​

• Prevent aspiration and skin breakdown​

• Keep eyeglasses and hearing aids readily available​

• Administer medications as prescribed

What are some Psychological interventions for Delirium?

• Provide interaction and support​

• Present reality as needed​

• Encourage expression of fears and discomforts​

• Provide a comfortable, orienting ​

• Reduce stimuli​

• Limit choices, Restraints as last resort

What are some Sociological interventions for Delirium?

• Utilize de-escalation techniques​

• Involve family if possible

What is Dementia?

A disease process marked by progressive cognitive impairment with no change in the level of consciousness

What Cognitive Disturbances are Associated w/ Dementia?

• Aphasia

• Apraxia

• Agnosia

• Disturbances in Executive Functioning

What is Aphasia?

• Deterioration of language function

  • starts with the inability to name familiar objects or people and then progresses to speech that becomes vague or empty with excessive use of terms such as it or thing

What is Apraxia?

• Impaired ability to execute motor functions

  • causes the client to lose the ability to perform routine self-care activities such as dressing or cooking​

What is Agnosia?

• Inability to recognize or name objects

  • particularly frustrating; may see a chair but be unable to name what it is​

What is a Disturbance in Executive Functioning?

• Inability to plan, initiate, sequence, monitor, and stop complex behavior

  • loses the ability to learn new material, solve problems, or carry out daily activities such as meal planning and budgeting​

What are the risk factors of Dementia?

• Advanced age​

• Prior head trauma​

• Lifestyle factors (e.g., sedentary)​

• Genetics (e.g., family history of Alzheimer’s dementia)​

• Metabolic syndrome or diabetes​

• Substance use or medication induced​

• Infections (e.g., HIV)

What are some causes of Dementia?

• Alzheimer’s disease​

• Vascular (multi-infarct) dementia​

• Lewy body dementia​

• Parkinson’s disease​

• Huntington’s disease​

• Prion Disease​

• Frontotemporal lobar degeneration (Picks diseases)

What is Alzheimer’s Disease?

• most common sub-type of major neurocognitive disorder.

• It is marked by global, progressive impairment of cognitive functioning, memory, and personality.

• It is irreversible and progressive

What is the Etiology of Alzheimer’s Disease?

• Loss of neurons and volume in certain brain regions​

• Beta-amyloid plaques​

• Neurofibrillary tangles​

• Cell death​

• Neurotransmitters​

• Genetic factors​

• Environmental factors​

• Oxidative stress, free radicals, mitochondrial dysfunction​

• Inflammation

What are some Preclinical stage signs of Alzheimer’s Disease Dementia?

Changes in brain, years before signs of disease​

Some mild memory loss​

No impact on judgment or ability to perform ADLs​

What are some Mild (early) stage symptoms of Alzheimer’s Disease Dementia?

Short-term memory lapses​

Unable to remember names of new people​

Forget familiar words​ ​

Lose or misplace items​

Impaired concentration​

Problem planning and organizing​

Able to perform ADLs​

What are some Moderate stage signs of Alzheimer’s Disease Dementia?

Confusion; progressive memory loss; forgetting events of own history​

Behavioral & personality changes​

↑ difficulty planning and organizing ​

May wander/get lost​

Sleep disturbances​

May be incontinent​

May need help w/ ADLs​

What are some Severe (late) stage symptoms of Alzheimer’s Disease Dementia?

Loses awareness of environment​

Loses ability to communicate w/ others​

Incontinent​

↑ difficulty with physical abilities​

Eventually impaired swallowing & total loss of movement ability​

Needs help w/ all ADLs & personal care​

What is Vascular Dementia (VD)?

• 2nd most common type of Dementia

• Characterized by a marked disruption in cerebral blood flow with destruction of brain cells ​

  • Blocked blood vessels leads to brain damage and cognitive impairment​

  • Can occur suddenly after blockage of major brain blood vessel​

  • reduces life expectancy to a greater degree than Alzheimer’s dementia

What are some Risk Factors of Vascular Dementia (VD)?

• Advanced age​

• Cerebral emboli or thrombosis​

• Atherosclerosis disease​

• Transient ischemic attacks or stroke​

• Diabetes, heart disease, hypertension​

• High cholesterol​

What causes Vascular Dementia?

• Occurs when small focal deficits, typically caused by a series of small strokes, accumulate.

• Tends to progress in stages and causes patchy distribution of cognitive problems

What are the s/s of Vascular Dementia?

• Often progressive; some S/S may occur rapidly if blockage is sudden​

• Impairments more localized (vs. global) compared to Alzheimer’s​

• S/S may include:​

  • Disorientation or confusion​

  • Dizziness​

  • Recent memory loss​

  • Wandering/getting lost​

  • Inappropriate emotions; depression​

  • Slurred speech​

  • Muscle weakness​

  • Problem following instructions or doing certain tasks​

  • Other S/S depending on site of blockage​

What are some General Nursing Interventions for Dementia?

• Establish baseline level of functioning; thorough assessment​

• Provide safety interventions as needed​

  • Restrict driving when person becomes forgetful​

  • Put mattress on the floor to reduce fall risk​

• Establish a therapeutic relationship with patient and family​

• Maintain independence as much as possible​

  • Provide ample time to perform ADLs in early stages of dementia​

• Use antipsychotics, antidepressants, mood stabilizers, anxiolytics with caution​

• Avoid medication with anticholinergic side effects​

What are some Pharmacological Interventions for Alzheimer’s Disease Dementia?

Cognitive symptoms (memory and thinking)​

Acetylcholinesterase inhibitors​

• Donepezil (Aricept) – mild, moderate, and severe stages of AD​

• Rivastigmine (Exelon) - mild to moderate stages of AD​

• Galantamine (Razadyne) - mild to moderate stages of AD​

Glutamate pathway modifier​

• Memantine (Namenda) - moderate to severe stages of AD​

Other​

• Memantine & Donepezil (Namzaric) - moderate to severe stages of AD​

What is Donepezil (Aricept) classified as?

Cholinesterase Inhibitor

What is Donepezil (Aricept) use to treat?

• Used for mild to severe Alzheimer’s Dementia​

• Causes reversible inhibition of acetylcholinesterase but is more selective for the form found in the brain (vs. the periphery)​

• Metabolized by CYP-450 enzymes

What are the AE of Donepezil (Aricept)?

• Nausea, diarrhea, bradycardia, fainting​

• To minimize side effects, titrate slowly

What are the Precautions/Contraindications with Donepezil (Aricept)?

Patient is at risk of falls and fall-related fractures

What Nursing Implications/Pt Education is needed w/ Donepezil (Aricept)?

• Like other cholinesterase inhibitors, does not affect the underlying disease process​

• Can be administered once a day due to prolonged half-life​

• Administer late in the evening​

• As with other cholinesterase inhibitors, does not affect the underlying disease process and benefits are modest and short-lasting

What class drug is Rivastigmine (Exelon)?

Cholinesterase Inhibitor

What is Rivastigmine (Exelon) used for?

• Used for mild to moderate Alzheimer’s Dementia​

• Unlike other cholinesterase inhibitors, converted into metabolites by acetylcholinesterase (not by CYP-450 enzymes)

What are the AE of Rivastigmine (Exelon)?

• Like other cholinesterase inhibitors, can cause peripheral cholinergic side effects (e.g., N/V, diarrhea, abdominal pain, anorexia—these occur more frequently than with other cholinesterase inhibitors)​

• Also like other cholinesterase inhibitors, can cause bradycardia, fainting​

• Causes irreversible inhibition of cholinesterase

What Precautions/Contraindications are needed w/ Rivastigmine (Exelon)?

• No significant drug interactions​

• Patient is at risk of falls and fall-related fractures​

• By enhancing cholinergic transmission, can intensify symptoms in patients with peptic ulcer disease, bradycardia, sick sinus syndrome, urinary obstruction, and lung disease; caution is advised

What Nursing Implications/Pt Education is needed w/ Rivastigmine (Exelon)?

• Available in a patch which is well tolerated because blood levels are lower and more steady; may be good for patients with difficulty swallowing​

• For oral route, give with food to reduce GI upset​

• Like other cholinesterase inhibitors, does not effect the underlying disease process and benefits are modest and short-lasting

What class drug is Galantamine (Razadyne)?

Cholinesterase Inhibitor

What is Galantamine (Razadyne) used to treat?

• Used for mild to moderate Alzheimer’s Dementia​

• Improves cognitive function, behavioral symptoms, quality of life, and ability to perform activities of daily living​

• Metabolized by CYP-450 enzymes; excreted by the kidneys

What are the AE of Galantamine (Razadyne)?

• N/V, diarrhea, anorexia, weight loss; GI complaints are greater than with donepezil but less than with oral rivastigmine​

• By increasing cholinergic stimulation in the heart, can cause bradycardia, fainting

What Precautions/Contraindications are needed for Galantamine (Razadyne)?

• Reduce dosage in patients with moderate hepatic or renal impairment​

• Discontinue in patients with severe hepatic or renal impairment​

• Patient is at risk of falls and fall-related fractures​

• Avoid drugs that block cholinergic receptors (e.g., first-generation antihistamines, typical antipsychotics, tricyclic antidepressants)​

• Adjust dosage in patients with hepatic or renal impairment

What Nursing Implications/Pt Education is needed w/ Galantamine (Razadyne)?

As with other cholinesterase inhibitors, does not affect the underlying disease process and benefits are modest and short-lasting

What class drug is Memantine (Namenda)?

N-methyl-D-aspartate (NMDA) receptor antagonist

What is Memantine (Namenda) used for?

• Indicated only for moderate to severe Alzheimer’s Dementia​

• For many patients, can slow decline in function; in some patients, may cause symptoms to improve; does not benefit mild Alzheimer’s Dementia​

What are the AE of Memantine (Namenda)?

• Better tolerated than cholinesterase inhibitors​

• Most common side effects are dizziness, HA, confusion, constipation

What Precautions/Contraindications are needed for Memantine (Namenda)?

• Use with caution with other NMDA antagonists (e.g., amantadine, ketamine)​

• Sodium bicarbonate and other drugs that alkalinize the urine can greatly decrease the renal excretion of memantine; such combinations should be used with caution

What are the Nursing Implications/Pt Education for Memantine (Namenda)?

There is no evidence that memantine modifies the underlying disease process

How does Suvorexant (Belsomra) treat symptoms of Alzheimer’s Disease Dementia?

• An orexin receptor antagonist (inhibits activity of orexin)​

• Prescribed to treat insomnia for people with dementia​

• Indicated for mild-to-moderate Alzheimer’s disease​

• Examples of possible side effects – risk of impaired alertness and motor coordination; worsening depression or suicidal thinking; complex sleep behaviors; sleep paralysis; compromised respiratory function

What class drug do Aducanumab (Aduhelm), Lecanemab (Legembi), and Donanemab belong to?

Monoclonal Antibodies

How do Aducanumab (Aduhelm), Lecanemab (Legembi), and Donanemab potentially change Alzheimer’s Disease progression?

• An anti-amyloid antibody IV infusion therapy – targets beta-amyloid plaques​

• Removal of amyloid plaques will likely reduce cognitive and functional decline​

• Currently only indicated for people with mild cognitive impairment or mild dementia stage of disease​

• Examples of most common side effects – amyloid-related imaging abnormalities (usually asymptomatic but can be serious), headache, and falls

What are the risk factors for older adult psychopathology?

• Chronic illnesses​

• Undetected or misdiagnosed illnesses​

• Alcohol and substance abuse​

• Polypharmacy​

• Adherence to treatment​

• Depression, bereavement, loss, or grief​

• Poverty​

• Lack of social support​

• Lack of use and/or access to available treatment and resources​

• Shared living arrangements and elder mistreatment

What are some Mental Illness Protective Factors in Older Adults?

• Marriage​

• Education​

• Income​

• Effective coping​

• Positive outlook​

• Healthy lifestyle​

• Adequate nutrition​

• Physical activity

What are some interventions to Promote Mental Health in Older Adults?

• Reduce the stigma of mental health treatment​

• Recognize depressive symptoms and suicide risk early​

• Monitor medications​

• Avoid premature institutionalization​

• Engage in cognitive activities/skills and problem-solving strategies​

• Encourage self-care​

• Facilitate social support​

• Encourage spiritual support​

• Refer to community services; assess for accessibility​

• Encourage a healthy lifestyle