Mental health WEEK 8 slides

Delirium and dementia similarities

Confusion/disorientation, impaired memory and attention span, anxiety and agitation, sundowning

Neurocognitive disorder

Previously known as Dementia

Sundowning

Increased confusing towards the end of the evening

Delirium risk factors

-Can be advanced age

-metabolic (kidney or liver failure)

-fluid/electrolyte imbalance

-cardiovascular disease/ respiratory disease

-*infection

-surgery

-substance use/withdrawal

-polypharmacy

-ICU (loses track of time)

-*males greater risk than females

Dementia risk factors

-advanced age

-prior head traumas

-cardiovascular disease/respiratory disease

-lifestyle factors (risky behaviors, drug use, no helmet)

-family history

Delirium

Disruption of thinking, memory, processing, and problem solving. Needs to be treated promptly (medical emergency), treatable. "Where THE F AM I"

Goal with delirium

Find out what the underlying issue is, treat it, and patient will be fine

Delirium key clinical features: where

Disorientated: check A&O x4 for severity, as severity progresses it goes in descending order- why are you at the hospital? What time? Where are you? Who are you? (Most severe)

Delirium key clinical features: thought disorganization

Non sensical statements, responds to commands that don't make sense, severe forms speech and language can be lost entirely. Cannot process things- asked to sign papers but responds by getting up and clapping

Delirium key clinical features: hallucinations

Majority are visual, patients appear to be responding to internal stimuli. Energy changes.

Delirium hyper active energy change

Restless babbling agitation, worse at night (sleep wake cycle reversed)

Delirium hypo activity energy changes

Slow sleepy low energy

Delirium Sleep wake cycle energy changes

Reversed, sleep during the day awake during the night

If a patient cannot sleep what interventions can we provide

Read a book, color, puzzle, relaxing non stimulating activities

Delirium key clinical features: fluctuating

Patient will appear to be cognitive during the morning and then in the afternoon have confusion and hallucinations, sundowning, acute: rapid onset, span of a few hours or days, can recover from rapidly if the underlying cause is treated, if prolonged illness s/s of delirium can persist longer

Fluctuating can be diagnostic in some causes because

In Dementia the confusion can be more consistent and enduring, Delirium cycles more rapidly within 24 hours, dementia cycles longer usually within a week

Medical causes/ intoxicants for delirium

PINCH ME: poorly controlled pain, infections (ie UTI), nutrition (ie poor diet and vitamin deficiency), constipation (common under-recognized trigger), hydration (dehydration), medications (can be prescribed or illicit drugs can trigger), endocrine (diabetes, thyroid disorder)

Treatment for delirium

Treat the underlying cause, re-orientation, promote sleep, antipsychotics and or antianxiety, curable

Dementia

Progressive neurodegenerative disease, cognitive decline that impairs daily functioning, permanent no cure

Types of dementia

Alzheimer's (70% of cases)

Vascular dementia (15%)

Dementia with Lewy bodies

Frontotemporal dementia (second most common)

Risk factors for dementia

Age is largest risk factor -age 65 has 2% prevalence age 85 has 40% prevalence, genetics, gender- females>males due to women living longer

Dementia s/s progressively

Get worse over time

Pre dementia S/S

Up to 10 years before clinical symptoms, mild symptoms: forgetfulness, poor orientation, changes in mood, struggling to find the right words, anosmia (loss of smell)

Early dementia s/s

Difficulties with- coming up with the right words or names, remembering names, forgetting material just read, losing objects or items, experiencing trouble planning

Middles dementia s/s

Increase difficulty with- forgetting personal history, feeling moody or withdrawn, unable to recall address phone number high school or college they attended, requiring help with choosing proper clothing, bladder control, sleep patterns, increased tendency to wander or get lost, increase paranoia, can have OCD type behaviors

Late dementia s/s

May require- round the clock care with ADLs, loss of awareness, difficulty communicating, vulnerable to infections especially pneumonia due to lying down a lot and sedentary lifestyle

Mild stage of dementia example

Frequently forgetting the little things "did I have an MD appointment today? Did I take my meds this morning? Where did I park my car?"

What are the safety concerns with mild stage of dementia

Not taking medications, doubling up on medication

Moderate stage of dementia example

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

What are the safety concerns with moderate stage of dementia

Stranger danger, not able to recognize known people or safe people

Severe stage of dementia example

Client may have now forgotten how to talk walk swallow or perhaps even breathe

What are the safety concerns for severe stages of dementia

Aspiration

The 4 As of dementia (Alzheimer's)

Amnesia (loss of Memory), apraxia (the loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them), agnosia (loss of ability to identify people or objects), aphasia (loss of ability to swallow)

Choline's erase inhibitors (dementia meds)

Goal is to increase acetylcholine at the neurotransmitter receptor site by stopping acetylcholinesterase from breaking down acetylcholine

Choline's erase inhibitors (dementia meds) names

Donepezil (taken at night w or w/o food)

Rivastigmine, galantamine

Choline's erase inhibitors (dementia meds) adverse effects

GI problems: nausea vomiting and diarrhea (watch for fluid and electrolyte imbalances), may be reduced if titrated

Syncope/bradycardia: screen for orthostatic hypotension and watch for fall risks

Blurred vision, dizziness, and sedation: monitor for falls

Urinary urgency

Choline's erase inhibitors (dementia meds) contraindications

Asthma, COPD (increased acetylcholine can cause Bronchoconstriction)

Choline's erase inhibitors (dementia meds) outcome/goal

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

Choline's erase inhibitors (dementia meds) interactions

No NSAIDS (increased risk of GI bleeding)

Choline's erase inhibitors (dementia meds) nursing considerations

-Never discontinue abruptly, taper down, can cause progression of clinical manifestations

-monitor for ability to swallow tablets in the elderly meds can come in a solution except donepezil

-medication to be taken at night before bed to sleep through major side effects

NMDA receptor antagonist (dementia meds)

Memantine, when glutamine levels rise in the brain it causes increase levels of calcium which can damage nerve cells, binds to the NMDA receptors and prevent binding

Of glutamate preventing the release of calcium

NMDA receptor antagonist (dementia meds) adverse effects

GI problems: nausea vomiting diarrhea constipation

NMDA receptor antagonist (dementia meds) contraindications

Pregnancy/breast feeding, epilepsy/ seizure disorder, severe hepatic and renal impairment

You are discharging an elderly client with moderate Alzheimer's disease what are some home safety measures you can teach the family to best keep the client free from accidental injuries

Toddler proof the house, add an additional lock to front door either higher up or down low, add rails along hallways stairs and in bathroom, label cabinets, remove rugs/electrical cords/ clutter, place bed mattress on the floor, remove stove nobs, set water heater at 95 degrees

Addiction

A disease of the pleasure pathways in the brain that also destroys all other pleasure pathways

Intoxication

Specific to the individual when the person has consumed excessive amounts for themselves

Tolerance

Needing more of the substance to achieve the desired effect, amount needed to feel physical effects

withdrawal

Typically begins 8 hours after last use the body experiences adverse effects as the chemical leaves the system

DSM-V criteria for substance use disorder

Loss of control (might want to quit but can't), large amounts 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 (stimulants)

Increase vitals mental activity and physical activity

Downers (depressants)

Decrease vitals mental activity and physical activity

If the drug causes increased vitals mental activity and physical activity what will occur with withdrawal

Withdrawal will cause decreased vitals mental activity and physical activity

If the drug causes decreased vitals mental activity and physical activity what will occur with withdrawal

Withdrawal will cause increased vitals mental activity and physical activity

Opioid pupillary response

Constructed during intoxication dilated during withdrawal

Opioids

Downer, attaches to CNS receptors to alter response to pain and causes CNS depression

Opioids examples

Heroin, morphine, hydromorphone, can be smoked inhaled or swallowed, causes pain relief and euphoria

Opioids intoxication

Slurred speech, decreased respirations, decreased LOC, antidote is naloxone

Opioids withdrawal

Sweating, irritability, weakness, diarrhea, pupil dilation, nausea, vomiting

What are patients at risk for during opioid withdrawal

Developing delirium

Alcohol/ cannabis

CNS depressant

Cannabis intended effects

Euphoria, sedation, can have hallucinations only in high doses, pain relief

Alcohol intended effects

Relaxation decreased social anxiety decreased stress

Sedatives/hypnotics/anxiolytics

Benzodiazepines, barbiturates, club drug (flunitrazepam)

Benziodiazepines antidote

Flumazenil (ROMAZICON)

What are patients at risk for with benzodiazepine withdrawal

Seizures

Barbiturates

Phenobarbital, no antidote

Club Drug

Flunitrazepam (roofies)

Alcohol use disorder cage questionnaire: C

Cut: do you ever feel like you should cut down on your drinking

Alcohol use disorder cage questionnaire: A

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

Alcohol use disorder cage questionnaire: G

Guilty: do you feel guilty about your drinking habits

Alcohol use disorder cage questionnaire: E

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

What are patients at risk for when withdrawing from alcohol

Seizures

Rules of engagement for med surge vs mental health with alcohol use disorder

All side rails up is a no go in med surge but yes is mental health for patient safety

Alcohol use treatment: withdrawal

Diazepam- agitation

Carbamazepine- seizures

Clonidine- blood pressure because stress/anxiety increases BP

Chlordiazepoxide- anxiety/agitation

Phenobarbital- anti seizure/sedative

Naltrexone- suppresses opioid cravings

Withdrawal can cause a decrease in thiamine which can cause brain swelling, treatment is vitamin B12

Alcohol use treatment: abstinence

Disulfram- deters alcohol use by causing unpleasant reactions (monitor for fluid/electrolyte imbalances)

Naltrexone- reduces cravings for alcohol and opioids

Acamprosate- supports abstinence in alcohol use disorder

Cocaine

CNS stimulant, rush of euphoria and pleasure and increased energy

Cocaine toxicity

-Hallucinations, seizures, extreme fever

-Cardiovascular collapse and death

Amphetamines/methamphetamines

Amphetamines rich people, methamphetamines poor people, causes rush of euphoria and pleasure increased activity, can cause extreme agitation irritability and hypervigilance

If a patient has a history of meth use what should the nurse do

Skin checks

Inhalants

CNS stimulant, amyloid nitrate, nitrous oxide, solvents used by kids, causes euphoria

Inhalants toxicity

Slurred speech stupor coma and respiratory depression

Inhalants withdrawal effects

None

Hallucinogens

CNS stimulant, LSD, Peyote, PCP, causes heightened sense of self and altered perceptions such as colors taste smell and feel and causes hallucinations

Hallucinogens withdrawal

Hallucinogen persisting perception disorder- causes visual disturbances and hallucinations that can last intermittently for years