Week 10 Dementia, Delirium, and Depression

define cognitive function

complicated process by which an individual perceives, registers, stores, retrieves, and use information

Cognitive impairment may be associated with what physical illnesses?

• stroke, heart disease

• Parkinson’s disease

• endocrine disorders

• cancers

• epilepsy

• B12 deficiency

• chronic pain

• viral illnesses

• Alzheimer’s

• lengthy hospitalizations

Cognitive impairment may be associated with what psychosocial factors?

• serious losses

• difficult relationships

• changes in social roles

• loneliness

• poverty

• unplanned moves/forced relocation

• medication side effects

Dementia

chronic, progressive, insidious, and permanent states of cognitive impairment, terminal

Delirium

an acute and sudden impairment of cognition that may be considered temporary

Depression

most often found, characterized by low mood, difficulty thinking & somatic changes

can also be pre-cursor to dementia

**Biggest risk factor for Alzheimer is

age

6th leading cause of death in the U.S.. Kills more than breast and prostate cancer combined

Alzheimer’s disease

State level factors about Alzheimer’s Disease

• 13% of seniors have AD

• in 2019, 3753 have died in NYS from AD

Costs of AD

• 2020: Alzheimer’s and other dementias cost the U.S. $305 billion

• 2050: these costs could rise to $1.2 trillion

Medications used to treat AD include

• Namenda- 7mg (30 tb): $451

• Aricept- 10mg (30tb): $270

• Excelon- 4.6mg (30 patches): $487

• Razadyne- 4mg (30 tb): $143

• Aduhelm- IV monthly $4312

Stages of Alzheimer’s Disease

1. Stage 1 Normal Adult

2. Stage 2 Normal Older Adult

3. Stage 3 Compatible with Early AD

4. Stage 4 Mild AD

5. Stage 5 Moderate AD

6. Stage 6: moderately severe AD

7. Stage 7: severe AD

Stage 1 AD: Normal Adult

no impairment

Stage 2 AD: Normal Older Adult

self report of memory impairment, no objective cognitive impairments are noted

Stage 3 AD: Compatible with Early AD

cognitive impairments recognized by others; anxiety; impaired performance in demanding work and social settings

Stage 4 AD: Mild AD

withdrawal, denial, depression; inability to perform ADLs and complex tasks, flattening of affect, cognitive impairment evident on exam

Stage 5 AD: Moderate AD

disoriented to time and place; needs assistance in clothing selection

Stage 6 AD: moderately severe AD

forgets name of spouse and other family members; personality and emotional changes; inability to perform many ADLs; agitation

Stage 7 AD: severe AD

loss of verbal and psychomotor skills; incontinence; needs total assistance

Other types of dementia

• Vascular dementia

• Lewy Body dementia

• Frontotemporal lobe

• AIDS dementia

• Trauma-MVA, falls

Vascular dementia

thought to be caused by cardiovascular factors, MI, stroke

Lewy Body dementia

similar to Parkinson’s Disease, protein deposits

Frontotemporal Lobe

personality changes & atrophy of frontal lobe, athletes with head injuries

make sure you can rule out delirium

Delirium symptoms

short term and long term memory impairment

Clinical diagnosis for Delirium

• loss of intellectual ability with impairment severe enough to interfere with social or occupational functioning

• delirium has been ruled out

What tests should be done if delirium is supected?

• CBC- infection?

• TSH- depression

• Basic Metabolic panel and LFTS-DM, drugs and alcohol

• Vitamin B12- deficit?

• MRI or CT- masses, lesions, tumors

Primary intervention for pts with dementia

symptomatic nursing care

Dementia is what type of illness?

life-limiting and a chronic illness

Symptomatic nursing care

• caregivers require training & expertise in long-term care and end-of-life care

• family caregivers require supportive care-respite

Pts with dementia develop

challenging behavioral and psychiatric symptoms

What to do with dementia pts

• alleviate symptoms

• teach pt and caregivers about the effects of dementia→ provide comfort + reduce feelings of distress

Planning care for pts with dementia

• promote independence and autonomy

• prevent avoidable complications

• promote quality of life

How to support dementia pt’s family

• do not assume the family understands basic care techniques

• assist, support and include them as part of the care

Things the nurse should do

• review basic specific care such as lifting, bathing, and managing inappropriate behaviors

• prepare family for the guilt, frustration, anger, depression and other feelings that accompany the responsibility of a caregiver

• assist the family with obtaining respite care

• encourage the family to network with support groups and obtain counseling as needed

How to create safe environment for dementia patients

• modify strategies used to prevent injury to toddles to provide a safer physical environment for older adult with dementia

• tour home with caregiver to identify safety issues and develop a safe plan

Delirium etiology

• disturbances in neurotransmission in the brain which control cognition, behavior and mood

• cholinergic failure

• poor cerebral blood flow

• complication of illness

• drug or substances effect on brain

• general anesthesia

Why is it difficult to detect delirium?

• often seen as confusion

• confusion is abnormal in youth and middle-aged adults but seen as normal in the elderly

• delirium over dementia is difficult to determine

Potential causes of delirium

• infections

• CNS masses

  • neoplasms

  • subdural hematomas

• medications

• dehydration

Nursing interventions

• orientation and therapeutic activities for cognitive impairment

• early mobilization to avert immobilization

• non-pharmacologic approaches to minimize the use of psychoactive drugs

• interventions to prevent sleep deprivation

• communication methods and adaptive equipment (vision and hearing impairments)

• early intervention for fluid volume depletion

Consequences

• significant distress

• high morbidity during hospitalization

• functional decline

• post-op complications

• increased length of stay

• low rate of recovery to prior level of functioning

• institutionalization

Types of Delirium

• Hypoactive

• Hyperactive

• patient is not acting like themselves

Hypoactive delirium

• quiet

• pleasantly confused

• lethargic

• inactive

• withdrawn

• limited, slow and wavering vocalizations

Hyperactive delirium

• Heightened Alertness

• Easily distracted

• Hallucinations

• Delusions

• Agitated

• Aggressive

• Fast &/or loud speech

• Wandering

• Repetitive movements

• Removing tubes

• Attempting to get out of bed

nursing interventions

• Re-assess cognition using established tools

• Be sure basic needs are met

• Review medications

• Understand behavior, determine root cause

• Maintain safety with minimal use of restraints

• Lessen invasive procedures

• Modify the environment

• Family involvement

Psychological adjustments

• Examples of common events requiring psychological adjustments

  • Widowhood

  • Confronting negative attitudes of aging

  • Retirement

  • Chronic illness

  • Functional impairments

  • Decisions about driving a car

  • Death of friends and family

  • Relocation from home to assisted living 

• The longer a person lives, the more likely events will occur that require coping and adaptation.

Risk factors for high levels of stress and poor coping

• Diminished economic resources

• Immature developmental level

• Unanticipated events, such as the death of a spouse

• Many daily hassles at the same time in one day

• Many major life events occurring in a short period of time 

• Unrealistic appraisals of situations

Depression may be associated with

• Stroke

• Heart disease

• Parkinson’s disease

• Endocrine disorders (diabetes)

• Cancers

• Epilepsy

• B12 deficiency

• Chronic pain

• Viral illness

• Serious losses

Depression

• Difficult relationships

• Changes in social roles

• Retirement

• Widowhood

• Loneliness

• Poverty

• Unplanned moves

• Medication side effects

• Age related changes

Depression risk can be decreased through (nonpharmalogical interventons)

• Nonpharmacological interventions

  • Light therapy for seasonal affective disorder (SAD)

  • Electroconvulsive therapy (ECT)

  • Psychotherapy

Depression risk can be decreased through (pharmalogical interventons)

• Pharmacological interventions 

 Antidepressants

 Mood stabilizers

 Antianxiety drugs

nursing interventions

• Assist older persons in identifying stressors and rating their levels of stress

• Help the older person identify successful coping mechanisms used in the past 

• Assist the older person in examining current coping mechanisms and behaviors 

• Alter or eliminate negative or maladaptive mechanisms

• Investigate community resources, support groups, stress-reduction clinics, and other stress relievers

• Encouraging appropriate self-care behaviors  

Healthy aging

• Healthy aging, social interaction, education, and problem-solving can be fostered through:

  • Travel with senior citizens groups

  • Outside activities

  • Taking classes

  • Elder hostels

  • Volunteer work

  • Regular exercise

  • Hobbies and crafts

  • Increased family involvement