neurocognitive disorders, substance use, and addictive disorders

neurocognitive disorders

the disruption of thinking, memory, processing, and problem solving

delirium

neurocognitive disorder (dementia)

similarities in delirium and dementia

confusion/disorientation

impaired memory/attention span

anxiety/agitation

sundowning

delirium risk factors

advanced age

metabolic issues (liver/kidney)

fluid/electrolyte imbalance

- dehydration

cardiovascular/respiratory disease

infection

- UTI most common

surgery

substance use/withdrawal

polypharmacy

- illicit OR pharmaceutical

ICU

being male

what is polypharmacy

when someone is taking many medications

can cause delirium in older people

- their kidneys and livers are aged and may not excrete the meds very efficiently

dementia risk factors

advanced age

prior. head traume

cardiovascular/respiratory disease

lifestyle factors

- smoking

family history

delirium

needs to be treated promptly, is a medical emergency

screening/assessment tools for delirium

CAM (confusion assessment method) assessment tool

NEECHAM (neelon-champagne) confusion scale

CAM

confusion assessment method

a diagnostic tool for delirium that uses a four-step algorithm, focusing on acute onset/fluctuating course, inattention, and either disorganized thinking or an altered level of consciousness

NEECHAM

neelon champagne confusion scale

a nursing assessment tool for rapid, bedside detection and monitoring of delirium by evaluating information processing, behavior, and physiological control

how do we recognize delirium

"Where THE F AM I" pneumonic

1. Where

2. Thought disordeintation

3. Hallucinations

4. Energy changes

5. Fluctuating

6. Acute

7-8. Medical causes / Intoxicants

"where" in delirium

disoriented

check A&O for severity

- where are you

- who are you

- what time is it

- why are you at the hospital

"thought disorganization" in delirium

non sensical statements

responds to commands that dont make sense

- ex. you tell them to sign these papers and they get up and start doing jumping jacks

in severe forms of delirium, speech and language comprehension can be lost entirely

"hallucinations" in delirium

majority are visual

pts will apear to be responding to internal stimuli (RTIS)

"energy changes" in delirium

hyper active

hypo active

sleep wake cycle

hyper active

restless

babbling

agitation

hypo active

slow

sleepy

low energy

sleep wake cycle

reversed

asleep during day

awake during night

"fluctuating" in delirium

pt will appear to be cognitive during the morning then have confusion and hallucinations in the afternoon

sundowning

this can be diagnostic in some cases

sundowning

signs, symptoms, and behaviors increase during hours of darkness

why can sundowning be diagnostic for delirium

because in delirium, they are often clear during the day then confused at night (sundowning)

compared to dementia, they will have a few days clear then a few days confused (not sundowning)

"acute" in delirium

rapid onset

span of few days or hours

can recover from rapidly if the underlying cause is treated

if prolonged, s/s can persist longer

"medical causes / intoxicants" in delirium

remember with "PINCH ME"

Poorly controlled pain

Infections (ex. UTI)

Nutrition (ex. poor diet, vitamin deficiency, malnutrition

Constipation

Hydration (dehydrated)

Medications (prescribed or illicit)

Endocrine (diabetes, thyroid disorder)

delirium treatment

treat underlying cause

re-orientation

promote sleep

antipsychotics/antienxiety meds

is curable

dementia

aka major neurological disorder

a progressive neurodegenerative disease

- cognitive decline that impairs daily functioning

- is permanent

dementia causes

vascular dementia (15%)

alzheimers disease (70%)

dementia with lewy bodies

frontotemporal dementia (second most common)

dementia risk factors

age

- age 65 has 2% prevalence rate

- age 85 has 40% prevalence rate

genetics

being female

- only because females live longer

stages of dementia

pre-dementia

early

middle

late

pre dementia

up to 10 years before clinical symptoms

forgetfulness

poor orientation

changes in mood

struggling to find the right words

anosmia

- loss of smell

early stage dementia

difficulty in thinking of right words or names

difficulty remembering names

forgetting materials just read

losing objects or items

difficulty planning

middle stage dementia

forgetting personal history

feeling moody or withdrawn

unable to recall address, phone number, high school/ college attended

needing help with choosing proper clothing

difficulty with bladder control

poor sleep patterns

increase tendency to wander or get lost

increased paranoia

can have OCD behavior

late stage dementia

around the clock care with ADLs

loss of awareness

difficulty communicating

vulnerable to infections

- especially pneumonia

mild stage dementia example

"did I have a doctors appointment today? did I take my meds this morning? where did I park my car?"

moderate stage dementia example

"have we met before? i'm lost and need to get home. wait, are you sure i own a car?"

severe stage dementia example

pt may have forgotten how to talk, walk, swallow, or even breathe

safety concerns for late stage dementia

aspiration

4 A's of dementia

amnesia

- loss of memory

apraxia

- cant carry out skilled movement and gestures despite having physical ability and desire to perform them

agnosia

- cant identify people or objects

aphasia

- cant swallow

dementia screening/assessment tools

functional dementia scale

brief interview for mental status

MMSSE

FAST

global deterioration scale

functional dementia scale (EPC)

helps nurse identify pts ability to perform self care, extent or memory loss, mood changes, degree of DTS/DTO

breif interview for mental status

used in long term care settings

MMSE

Mini Mental Status Exam

30 items, 24-30= no cognitive impairment; 18-23=mild cognitive impairment; 0-17= severe cognitive impairment

FAST

a scale used to assess the progression of dementia by evaluating a person's functional abilities and daily living skills through seven stages

global deterioration scale

measures clinical characteristics at 7 levels based on the progressive stages of AD

dementia meds

cholinesterase inhibitors

goal is to increase acety;choline at neurotransmitter receptor site by stopping anticholinesterase from breaking down acetylcholine

donepezil

cholinesterase inhibitor

rivastigmine

cholinesterase inhibitor

galantamine

cholinesterase inhibitor

donepezil nursing considerations

take at night

can take with or without food

cholinesterase inhibitor aderse effects

GI problems

- N/V/D

- need to watch for dehydration, fluid/electrolyte imbalance

- can be reduced if titrated

syncope/bradycardia

- orthostatic hypotension

blurred vision/dizziness/sedation

- fall risk

urinary urgency

- make sure they have bathroom/commode in room

cholinesterase inhibitor contraindications

asthma

COPD

*increased acetylcholine can cause broncioconstriction

goal of dementia meds

improve ability to perform self-care and slow cognitive deterioration in mild to moderate stages

cholinesterase inhibitor interactions

NSAIDs

*can cause GI bleed

cholinesterase inhibitor nursing considerations

never discontinue abruptly

- must taper down

- can cause progression of clinical manifestations

monitor ability to swallow tablets

take at night before bed

- allows them to sleep through side effects

other dementia meds

NMDA receptor antagonist

- memantine

memantine

when glutamine levels rise in the brain, this causes an increase in Ca levels, which can damage nerve cells

memantine binds to NMDA receptors and prevents binding of glutamine preventing release of Ca

memantine adverse effects

GI problems

- N/V/D

constipation

memantine contraindications

pregnancy/breastfeeding

epilepsy/seizure disorder

severe hepatic/renal impairment

home safety measures for dementia pt

locks on doors

- so they dont wander out

lock meds and chemicals

no rugs/cords

- tripping hazard

water heater at 105

addiction

both voluntary and involuntary

- initially voluntary then becomes involuntary

intoxication

amount of substance to feel physical effects

not the same for everyone

tolerance

amount that someone can handle

withdrawal

the discomfort and distress that follow discontinuing the use of an addictive drug

for alcohol, can begin 2-3 days after last consumption

DSM-V criteria for substance use disorder

loss of contorl

- may want to quit but cant

large amount of time spent on acquiring the drug, using the drug, or recovering from excessive use of the drug

negative impact on role responsibilities

displaces tolerance and withdrawal

addictive substances

alcohol

amphetamines

benzos

cocaine

opioids

caffeine

cannabis

hallucinogens

inhalants

tobacco

uppers

substances that increase vitals, mental activity, and physical activity

amphetamines

cocaine

hallucinogens

etc

downers

substances that decrease vitals, mental activity, and physical activity

alcohol

benzos

opioids

cannabis

etc

theme for withdrawal

if theyre going up during intoxication (uppers), theyll go down during withdrawal

if theyre going down during intoxication (downers) theyll go up during withdrawal

opioids

attaches to CNS receptors

alters response to pain

causes CNS depression

heroin

morphine

hydromorphone

can be smoked, inhaled, or swallowed

causes pain reliefe and euphoria

opioid intoxication

slurred speech

decreased respirations

decreased LOC

antidote for opioid intoxication

naloxone (narcan)

opioid withdrawal

sweating

irritability

weakness

diarrhea

pupil dilation

N/V

CNS depressants

alcohol

cannabis

sedatives/hypnotics/anxiolytics

- benzodiazepines, barbiturates, club drugs

alcohol intended effects

relaxation

decreased social anxiety

decrease stress

cannabis intended effects

euphoria

sedation

hallucinations in high doses

pain relief

benzodiazepines

diazepam

benzodiazepines antidote

flumanzenil

barbiturates

pentobarbital

barbiturates antidote

no antidote

club drugs

flunitrazepam

aka roofie drug

CAGE questionnaire

for alcohol use disorder

Cut: do you feel you should cut down your drinking?

Annoy: do you get annoyed when people criticize your drinking?

Guilty: do you feel guilty about your drinking habits?

Eye opener: do you ever need a drink/eye opener first thing in the morning to get your day started?

alcohol withdrawal agitation treatment

diazepam for agitation

alcohol withdrawal seizure treatment

carbamezepine

alcohol withdrawal blood pressure treatment

clonidine

alcohol withdrawal anxiety treatment

chlordiazepoxide

alcohol withdrawal sedatibe/antiseizure treatment

phenobarbital

alcohol withdrawal cravings treatment

naltrexone

abstinence meds for alcohol

disulfiram

naltrexone

acamprosate

CNS stimulants

cocaine

amphetamines

methamphetamines

inhalants

hallucinogens

cocaine effects

rush of euphoria and pleasure

increased energy

cocaine toxicity

hallucinations

seizures

extreme fever

- from extremely high HR (can be in 200s)

cardiovascular collapse and death

amphetamines

drugs that stimulate neural activity, causing speeded-up body functions and associated energy and mood changes

can be prescribed medication

ex. adderall

methamphetamines

highly addictive drug that stimulates CNS

ex. battery acid, household cleaning supplies

amphetamines and methamphetamines effects

rush of euphoria and pleasure

increased energy

can cause extreme agitation, irritability, and hypervigilance

inhalants

amyl nitrate

nitrous oxide

solvents used by kids

inhalants effects

euphoria

inhalants toxicity

slurred speech

stupor

coma

respiratory depression

inhalants withdrawal effects

none

but can damage your brain long term

hallucinogens

LSD

peyote

PCP

hallucinogens effects

heightened sense of self and altered perceptions such as colors, taste, smell, and touch

hallucinations

hallucinogens withdrawal

hallucinogen persisting perception disorder

- visual disturbances, hallucinations, and paranoia that can last intermittently for years

- you can do hallucinogens once and have these effects for years

opioid withdrawal medications

methadone

buprenorphine

clonidine

naltrexone