Elderly, grief, cognitive Ch.23/31

Describe the assessment findings of patients with
neurocognitive disorders (5)

What are the signs and symptoms of delireum

uDisturbance in attention- reduced ability to focus, sustain attention.

uAbrupt onset with periods of lucidity

uDisorganized thinking

uPoor executive functioning

uDisorientation

uAnxiety and agitation

uPoor recall

Delusions and hallucinations (usually visual)

Describe the assessment findings of patients with
neurocognitive disorders (5)

What are the signs and symptoms of delireum

uDisturbance in attention- reduced ability to focus, sustain attention.

uAbrupt onset with periods of lucidity

uDisorganized thinking

uPoor executive functioning

uDisorientation

uAnxiety and agitation

uPoor recall

Delusions and hallucinations (usually visual)

How do we assess delirum

uOverall assessment

uFour cardinal features of delirium

1.  Acute onset and fluctuating course- might not be A0 × 4

2.  Possibility of delireum should be considered when py has a reduced clartity of awreness Reduced ability to direct, focus, shift, and sustain attention

3.  Disorganized thinking- might not be able to remeber who you are

4.  Disturbance of consciousness- memory defciit, disorentayion

uCognitive and perceptual disturbances

uIllusions- The stimulkus is a real object

uHallucinations- false sensorty stimuli - visual

uPhysical needs-make the phys enviornment simple give clocks, glasses, hearing aids. Skin breakdowb ex. incontinecne

uMoods and physical behaviors- agitation , behavior flucuates,

uSelf assessment-

they can be aware that something is wrongPossibility of delireum should be considered when py has a reduced clartity of awreness , when stare straight through you and dont know who you are.

Worse during night and early morning

Autonomic signs- tachycardia, sweating, flushed, dilated pupils, elevated n[

Diff falling alseep, disroentied and agitated at night.

What outcome/ planning do we do for delirum

˜Outcomes criteria

uPatient will remain safe and free from injury

uDuring periods of clarity, patient will be oriented to time, place, and person

uPatient will remain free from falls and injury while confused, with the aid of nursing safety measures

˜Planning

uEnsure necessary aids and supportive home team

uVisual cues in the environment for orientation Ex. are there family members able to stay w patient , does the enviornemnt provide visual cues to time od day and season of the year. Has the person experienced Continuity of care providers

uImplementation

uPrevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance.

uMinimize use of restraints (increases confusion)

uPerform comprehensive nursing assessment to aid in identifying cause.

uAssist with proper health management to eradicate underlying cause.

uUse supportive measures to relieve distress.

What a major neurocognitive disorders

uAlzheimer’s disease-

Early -diffic remembering events, names, conversations, depression

Mild- impaired commun, disoriented, confused, poor judgme, behavior changes

Late- diff speak, swallow, walking

uFrontotemporal dementia- 45-60 yrs , changes in personality, diff w comm,
Disinhibition refers to the inability to withhold an inappropriate or unwanted behavior

uDementia with Lewy bodies- sleep disturbinaces, visual hallucinat, movemnet and difficult to work out where things are or to judge how quickly something or someone is moving- visuospatial impair

uVascular dementia- impaired judment poor decion making, slow gait and poor balance

uTraumatic brain injury

ØSubstance-induced dementia

ØHIV infection

ØPrion disease

ØParkinson’s disease

Huntington’s disease

What is alzheimers

uAlzheimer’s: 60% to 80% of all dementias

uImportant to distinguish normal forgetfulness and memory deficits in dementia

uIn dementia: memory loss interferes with ADLs

uAD progression

uMild- diff remmeb names, performing taks, misplac objects, touble w organizing

uModerate- confuse words, get frusturates, become moofy, dont know thier adress, phone number, confused aout where they are and what day it is, need help choosing clothes, becomes delusional or compulsive, chnages in sleep patterns

uSevere- cant respond to their enviornment, cant continue conversation, have personality chnages, may reuire full assistance, changes in physi ability- cant walk, swallow, diff communication, become vul to infect

AD attacks indiscriminatory- Affects all.

uAssessment- progressive deterioating of cognitive functioning

uDefense mechanisms

uDenial

uConfabulation (creation of stories in place of missing memories to maintain self-esteem) It is not lying- they are unaware - unconsious mechanism to protect the ego

uPerseveration (repetition of phrases or behavior) or gesture that contnues after the orginial stimulus has stopped. For ex. when someone keeps repeateing hello after already said hi

uAvoidance of questions

uSelf assessment

Compare tables 23.4 between AD and Dementia

delirum- sudden onset, dementia slow over months and years

delirum has an underling medical conditions, alzhemiers- dt/ vascular disease, HIV, neuro disease, chronic alcholism, head trauma

delirum- impaires atten span, diorenation, disturbances in perception, ALzhe- impaired memory, judegment, attention span, claculation, abstract thinking, agnosia- cant recognize objects/ people

dlirum- sleep wake cycle change, alzhe- hevaior worsne sundown

delirum- rapid swings, anxious, agress, delusion halluc

alzhe- flat, agitation

Table 23.5 Problems with patients and family

Support to care givers

feel like theyre a burden to family, mix night and day, repetion of actions, questions and storeies, suspison, hiding, hoardinh,

What are the s/s of alzhemiers

uMemory impairment

uDisturbances in executive functioning

uAphasia: Loss of language ability- might not be able to say words. Initially the person has difficulty findining the correct word then is reduced to a few words, babbiling.

uApraxia: Loss of purposeful movement, ex. cant put on clothes

uAgnosia: Loss of sensory ability to recognize objects-EX. cant rember familar sounds, objects- ex. toothrbuch, magazine

What are the diagnostic tests we do for alzhemiers

uDiagnostic tests

uComputed tomography scan (CT)

uPositron emission tomography (PET)

uMental status questionnaires

uMini-Mental State Examination

uComplete physical and neurological exam

uComplete medical and psychiatric history

uReview of recent symptoms, meds, and nutrition

How do we help people w alzhemiers

uSelf-assessment

uRealistic understanding of the disease

uStress management

uSupport and educational resources

uRealistic outcomes and recognition when these are achieved

uMaintaining good self-care

uPlanning- focus on immed needs, asses caregiver needs

uConnect caregivers to support services

evaluate saefty in their home, ex. wandering, exlpore how well family is prepappred for this, resoucrces

uIntervention

uPerson-centered care approach- develop meanignful realtion w pt and caregiver

uHealth teaching and health promotion-

uReferral to community supports

uPharmacological interventions

uIntegrative therapy- nutriton, omega 3 fatty acids

uEvaluation

Evaluate client’s feelings about Alzheimers disease diagnosis (2)

Family grief- help the family grieve

Plan care for patients with neurocognitive disorders (2)

Explore mental health issues and healthcare concerns related
to aging. (4)

Identify end of life needs (financial, fear of loss control, role
changes) (2)

Provide end of life care education to clients (2)

valuate coping for a client experiencing grief or loss (2)

A woman brings her mother to your clinic, concerned that her 85-year-old mother may have dementia.

     “I’m Ellen,” she says when you enter. “This is my mother Veronica. She’s not much of a talker these days, so I’ve come with her to help her express a few things we’re both a bit worried about.”

     “Right now,” Ellen says, “we’re pretty sure she has either delirium or dementia, maybe. What’s the difference between those two?”    

Ellen continues: “Well, it’s mostly a problem with memory that started maybe two years ago? One and a half, maybe?”

      You ask, “Did something abrupt set this off?”

     “No,” Ellen says. “Mom? Do you think some event may have triggered all this?”

     Veronica shakes her head. 

     “Does she have abrupt moments of lucidity?” you ask.

     “Not really,” Ellen shakes her head. “She’s pretty much the same all the time.”    

Which is an indication that Veronica does not have delirium?

A.She seems confused.

B.She gets anxious and agitated.

C.She seems disorganized in her thoughts.

Her problems with memory have been developing gradually

Her problems with memory have been developing gradually

Ellen describes Veronica’s problem further.

     “She has trouble remembering things, like where she put the electric bill. I helped her find it, and I thought that was that.”

     “But then, the next week I picked her up for a lunch date, and she looked really nice, no problem with that; she was already to go, but her house was freezing!!!” I said, “Mom, did you pay your electric bill?”

     She just stared at me.

Ellen continues:  “But then, the next week I picked her up for a lunch date, and she looked really nice, no problem with that; she was already to go, but her house was freezing!!! I said, “Mom, did you pay your electric bill?”

     She just blinked at me. “I don’t know,” she said.

     “’Well, okay,” I said. “Let’s see. Where’s your checkbook?”

     “‘I don’t know,’ she said. ‘Just stop asking questions!’ I thought she was going to cry!”

Veronica tries to refer to the electric bill, but ends up saying, “you know, the invitation. The invitation”. What is this a sign of?

A.Aphasia

A.Apraxia

B.Agnosia

C.Perseveration- repetion of a word , phrase

Aphasia

Veronica’s AD has progressed. One morning, she attempts to brush her teeth with a spoon. Which problem is evident?

A.Aphasia

B.Apraxia

C.Agnosia

Perseveration

Agnosia- loss of ability to recogni objects

Acute onset of disordered thinking is most associated with:

A.delirium.

B.Alzheimer’s disease.

C.frontotemporal dementia.

D.dementia with Lewy bodies.

delirum

Your patient, 85-year-old Veronica, is diagnosed with Alzheimer’s disease. What are some next steps you as her nurse can help with as both patient and family adjust to this news?  

Evaluate the person's current level of cognitive and daily functioning.

2.  Identify any threats to the person's safety and security and arrange their reduction.

3.  Evaluate the safety of the person's home environment (e.g., with regard to wandering, eating inedible objects, falling, engaging in  

     provocative behaviors toward others).

4.  Review the medications (including herbs, complementary agents) the patient is currently taking.

5.  Interview family members to gain a complete picture of the person's background and personality.

6.  Explore how well the family is prepared for and informed about the progress of the person's dementia, depending on the cause (if known).

7.  Discuss with family members how they are coping with the patient and their main issues at this time.

8.  Review the resources available to the family. Ask family members to describe the help they receive from other family members, friends,  

     and community resources. Determine whether caregivers are aware of community support groups and resources.

9.  Identify the needs of the family for teaching and guidance (e.g., how to manage catastrophic reactions, lability of mood, aggressive

     behaviors, and nocturnal delirium and increased confusion and agitation at night [sundowning]).

WHat are mental health issues related to aging

˜Depression—not a normal part of aging

˜Aging and suicide risk—white males older than age 75 at highest risk

˜Anxiety disorders- geenralzed anxiety dusorder associated w pain, Axniety probelm- fair of falling.

˜Delirium—secondary to general medical condition, hapopens over short time. Ex. if patient is newly confused, falling, disrobbing and fighting w workers- asssess them for delirum. Ask questions- has your mom been shopping/ cooking for herself, does she pay her own bills

˜Neurocognitive disorders-

Aphasia- Difficult finding words

Apraxia- diffciulty carrying out motions - this can lead to not making meals, not being able to pay bills

Agnosia- failure to recognize objects

˜Alcohol use disorder- usuaylly do to enviornmental factors ex. reteriemnt, widohood, lonliness

˜Pain-

How do we manage pain in older adults

˜Barriers to accurate pain assessment- they may beleive that pain is a normal inevitable thing happen, that theyre gonna die, sign weak, too expens to daignose

˜Assessment tools

ØWong-Baker FACES Pain Rating Scale

ØPresent pain intensity (PPI) rating from the McGill Pain Questionnaire (MPQ)

ØPain Assessment in Advanced Dementia (PAINAD) scale

˜Pain management

ØPharmacological pain treatments- non opidods- but they dont decrease inflamm, initat doses should be lowwered, nsaids, aceotmenophin- txic liver,

ØNonpharmacological pain treatments-

What are some health care concerns of older adults

˜Financial burden- healthcare4x more expensive than others . 10% live below poverty level. AARP- reteried peple- have free assistance in selecting a mediare plan that can cover their meds.

˜Caregiver burden- amount of physcial, emotional, fianical, psychological support

˜Ageism- discrimination against older people

ØAgeism and public policy- finanical and political support system are harder to fidn as you get older

ØAgeism and research= older aults are not in clinical trials of medications- FDA said they should be

What are health care decision making

˜Advance directiveshow you want you medical decions to be made if yiu lose the ability to make them for yoursled

Gaurdianshio- court ordered relationship where one gaurdian acts on behald of the indiediya;.m

ØPatient Self-Determination Act- enocurages all people to enage in decisons about the types and extenent of medical care they want to acceptor or reduse whenever they are unable to make these decisons dt ilnesss. This requires health care agencies to recgonixe the libing will and power of attorney. Established a call for patients to be free from any unessary drugs or restraints.

ØPsychiatric advance directives

˜Living will- a writeen document stating how uou want to make to make decisons cant for uoir seld. Spells out what life prolonigin meansure should be taken if theres no hope recoveru

˜Directive to physician- notifying the pyshcian of behavioral changes

˜Durable power of attorney for health care

˜Guardianship

What are intervention strategies

˜Environmental intervention

˜Psychosocial interventions

˜Pharmacological interventions

˜Promotion of self-care activities

˜Teamwork and safety

What are care settings

˜Skilled nursing facilities

˜Residential care settings

˜Partial hospitalization

˜Day treatment programs

˜Behavioral health home care

Community-based programs

Mr. Nixon is being admitted to a short-term care facility because his wife, who had been his only caretaker, has recently died. His son, who lives about 250 miles away, has been staying with him for the past 4 weeks, but has to go home now to go back to work.

     Mr. Nixon has COPD and has trouble getting around because he gets short of breath.
     You will be doing an intake assessment with Mr. Nixon.

You are preparing to interview Mr. Nixon. What are some techniques the nurse could use to help the patient feel more comfortable?

Conducting the interview in a private area

Introducing oneself and asking the patient what he or she would like to be called (use of the first name is rarely appropriate unless one is invited to do so)

Establishing rapport and putting the patient at ease by sitting or standing at the same level as the patient

Ensuring that lighting is adequate and noise level is low, in recognition of the fact that hearing and vision may be impaired

Using touch (with permission) to convey warmth, while at the same time respecting the patient's comfort level with personal touch

Summarizing the interaction, inviting feedback and questions, and thanking the patient for giving his or her time and information

]

Mr. Nixon, who has difficulty walking because of shortness of breath secondary to COPD says, “Every day is a struggle when you get old. No one cares about old people.” Select the best response.

A.“Rest periods are important. Don’t try to overexert yourself.”

B.“It sounds like you’re having a difficult time. Tell me about it.”

C.“Let’s not focus on the negative. Tell me something good.”

D.“You are still able to get around, and your mind is alert.”

ANS:  B

A community mental health nurse plans an educational program for the staff of a home health agency specializing in care of the elderly. A topic of high priority should be

A.identifying clinical depression in older adults.

B.identifying nutritional deficiencies in the elderly.

C.providing cost-effective foot care for the elderly.

D.psychosocial stimulation for those who live alone.

ANS: A

Mr. Nixon needs help with his prescription ordering. Which component of Medicare assists seniors to pay for prescription drugs?

A.Part A

B.Part B

C.Part C

Part D

ANS: D

 

Medicare Part D pays 75% of total drug costs, after a $275 deductible, up to the initial limit of $2,510.

A family member of a patient with advanced dementia says to the nurse, “I will sign the consent for my mother’s surgery.” What is the nurse’s best response?

A.“This should be a family decision. When will your siblings arrive?”

B.“Can you please show me the Court order designating you as guardian?”

C.“Thank you. Please use a black ballpoint pen to sign.”

D.“The patient is able to sign her own consent.”

ANS: B

 

A guardianship is a court-ordered relationship in which one party, the guardian, acts on behalf of an individual, the ward. Many people with mental illness, mental retardation, traumatic brain injuries, and organic brain disorders, such as dementia, have guardians. It is important that health care workers identify patients who have guardians and communicate with the guardians when health care decisions are being made.