Class 8: Psychosis, Cognition, Elimination

May be related to poor care, ut it is also a likely consequence of intersection of factors such as

1. Illness

2. normal age changes

3. environmental factors (ex: heat)

That combine to result in increased fluid loss/ decreased fluid intake

Why might dehydration happen?

1. Changes in thirst mechanism

2. change in kidney functions

3. Decreased total body water

Age-related changes that are risk factors for dehydration:

1. Directly affects renal function and fluid balance (diuretics)

2. Polypharmacy

Medication risk factors for dehydration [2]

1. Fluid and NPO restrictions

2. High environmental temperature

3. Inadequate assistance with fluid intake (dementia, busy nursing home, etc.)

Environmental risk factors (health interventions” that are risk factors for dehydration [3]

1. Diarrhea, vomiting, bleeding, infection, fever, etc.

2. Depression, dementia, delirium

3. Dysphagia (impaired swallowing)

4. multimorbidity

Illness and functional impairment risk factors for dehydration [4]

1. Age related changes

2. medications

3. environmental factors

4. illness and functional impairment

Four categories of risk factors for dehydration :

Older adults already have reduced skin turgor.

Why is reduced skin turgor not a reliable sign of dehydration in older people?

1. Dry mouth, grooved tongue

2. difficulty speaking

3. sunken eyes

4. dry axillae

5. weakness, dizziness

Dehydration signs and symptoms to be aware of in older adults: [5]

Oral hydration

First line of intervention for people with mild to moderate dehydration who can drink:

Hypodermoclysis

Infusion of isotonic fluids into the subcutaneous space to treat dehydration in those who cannot drink

Replace half of the lost fluid in the first 12 hours, further rehydration can be extended over a longer period of time.

What is the aim of dehydration interventions?

1. decreased bladder capacity

2. Increased bladder irritability

3. Incomplete emptying

Age-related changes in bladder funcion: [3]

1. Frequency changes

2. urgency

3. vulnerability to infection

4. short “warning period”

Age-related changes in bladder function may lead to: [4]

Urinary incontinence

Involuntary loss of urine, considered as a geriatric syndrome

1. Illness

2. Cognitive impairment

3. mobility impairment

4. lack of access to facillities

When paired with age related changes, what can cause urinary incontinence? (age-related changes alone do not cause urinary incontinence)

1. Falls

2. Pressure ulcers

3. depression

4. social isolation

5. avoidance of sexual activity

6. significant economic burden

Consequences of urinary incontinence:

19% of men and 22% of women

Prevalence of urinary incontinence in men and women over 85

60-90%

Prevalence in urinary incontinence in nursing home residents

Transient urinary incontinence

A sudden onset of urinary incontinence, <6 months, with treatable factors (delirium, UTI, diuretics, restraints, bedrest, etc.)

Established urinary incontinence

Urinary incontinence with a gradual onset

1. Urge incontinence

2. Stress incontinence

3. Urge or stress incontinence with high postvoid resitudal

4. functional incontinence

Types of established urinary incontinence: [4]

Urge incontinence

established urinary incontinence with inability to suppress sudden urge; loss of large amounts of urine; most common type

Stress incontinence

Involuntary loss of small amounts of urine during actions that increase intra-abdominal pressure (coughing, sneezing, lifting, etc.)

Urge or stress incontinence with postvoid residual (aka overflow urinary incontinence)

Inability to completely empty the bladder; characterized by hesitancy, slow urine stream, and frequent or near constant urine loss

Functional incontinence

inability to reach a toilet due to environmental barriers, mobility, or cognitive impairment

1. health history

2. targeted physical exam

3. urinalysis

4. measuring post-void residual

Further assessment when preventing and managing urinary incontinence:

Insert a catheter through urethra and into bladder. Any urine left in bladder drains out through the catheter. Nurse measures this and drains out.

How to measure post-void residual:

With prevention. Pay attention to iatrogenic factors (e.g., find alternatives to restraint, avoid bedrest, ensure adequate fluid intake, help mobilize to the bathroom, etc.)

How do urinary incontinence interventions begin?

1. scheduled voiding to treat urge and functional urinary incontinence. Regular toileting every 2-4 hours

2. Prompted voiding combines scheduled voiding with monitoring and prompting along with positive feedback

Effective treatments for urinary incontinence include: [2]

1. fever

2. flank or abdominal pain

3. new-onset incontinence

4. diminished appetite

5. altered mental status

UTI symptoms to be alert for

Indwelling catheters

Common cause of UTIs that are not appropriate for long-term use:

fecal incontinence

Uncontrolled passage of fecal material > 1 month

50-65% (but can be improved or even resolved)

Prevalence of fecal incontinence in LTC

Delirium

Acute confusion, a transient and etiologically nonspecific organic mental syndrome, defined as a medical emergency

1. Reduced ability to focus, sustain, or shift attention

2. Disturbance of consciousness or cognition (memory loss, disorientation and/or language disturbance)

How is delirium characterized?

1. Hyperactive

2. hypoactive

3. mixed

Types of delirium:

Hyperactive

Type of delirium where person is agitated, restless or combative and may experience hallucinations:

Hypoactive

Type of delirium where person may be sleepy, lethargic, difficult to rouse, may go unrecognized (higher mortality rate)

Mixed

Type of delirium that may alternate between agitation and lethargy

Occurs shortly after admission to the hospital, usually between the 3rd and 6th day of hospitalization

When is delirium onset most likely to occur?

Onset is always acute or sub-acute developing over a short period of time (usually hours to days) and tends to fluctuate over the course of the day, often worsening at night .

types of onset of delirium:

1. full recovery with early detection and intervention,

2. progression to stupor and/or coma, seizures, and death.

Possibilities for delirium outcomes: [2]

comorbidity of illness

3-4 diagnoses

1. advanced age

2. dementia

3. severe illness

4. comorbidity of illess

5. alcoholism

6. constipation

7. pain

8. envrionmental

9. depression

10. sensory impairment

11. dehydration

12. polypharmacy

13. Symptomatic infection

14. Previous episodes of delirium

Risk factors for delirium [14]

1. Greater in-hospital functional decline (longer recovery)

2. greater intensity of nursing care

3. more frequent use of physical restraints

4. increased length of hospitalization, and higher hospital mortality rates due to delirium

5. Worse outcomes of severe delirium

Consequences of delirium for patients and the health care system [5]

Delirium

Most common complication of surgery

35-60%

Prevalence of delirium in LTC

1. rapid onset

2. fluctuating symptoms

3. lasts days to weeks

4. level of consciousness fluctuates with inability to concentrate

5. sleep/wake cycle may be reversed (worse at nigt)

How id delirium different than dementia? [5 signs]

1. onset is progressive

2. vital signs are normal

3. hallucinations are auditory

4. Oriented

How is psychosis different from delirium?

1. reduce risk factors

2. promote a sense of familiarity and security

3. Provide comfort, adequate nutrition and hydration, and rest.

How to prevent delirium

The CAm (Confusion Assessment Method questionnaire)

The assessment and identification of delirium tool:

1.Acute onset with fluctuating course

2.Inattention

3.Disorganized thinking

4.Altered level of consciousness

5.Disorientation

6.Memory impairment

7. Perceptual disturbances

8. Psychomotor agitation and retardation

9. Altered sleep-wake cycle

Types of questions in the CAM test

Recovery, most completely resolves within 1-4 weeks

Most common outcome of delirium cases:

•Obtain treatment for underlying cause (importance of collaboration with MD/ NP)

•Ensure daily needs are being met (nutrition, hydration, rest, etc.)

•Monitor closely to ensure safety

•Create a safe and supportive environment (prevent self harm, reduce stimulation, provide adequate lighting, etc.)

Communicate clearly and simply – connect with the person

Nursing process intervention for delirium: [5]

1. Presence of family members

2. familiar items from home

3. night-light and minimal noise

4. not interrupting sleep

5. max. visualization of patient

6. one-to-one constant supervision

7. avoid restraints (or brief use)

8. plan effective communication

how to create a supportive environment for delirium management? [8]

1. large, easily visible clock and calendar

2. board with names of care team members

3. daily schedule

4. integration of orienting cues into patient’s daily routine

Communication strategies for someone with delirium that are aimed at reorienting the patient to surroundings: [4]

1. discussion of current events

2. discussion of specific interests

3. structures reminiscence

4. word games

Cognitive enhancing strategies for delirium management [4]

Only if person is dangerous to self or others, or to correct sleep disturbances

when should pharmacological strategies used to treat delirium?

Addressing underlying medical conditions and causes

Treatment for delirium: