Schizophrenia and Dementia: Comprehensive Study Notes
Schizophrenia: Positive Symptoms
Definition: Positive symptoms are things that are present but normally should not be. They add to the client's experience.
Examples:
Hallucinations: Perceptions in the absence of external stimuli (e.g., auditory, visual, tactile, olfactory).
Delusions: Fixed, false beliefs that are not amenable to change in light of conflicting evidence.
Alterations in Speech: Disturbances in the form and content of spoken communication.
Bizarre Behavior: Any unusual or odd behavior, including alterations in movement.
Alterations in Movement: A component of bizarre behavior, such as repetitive or involuntary movements.
Schizophrenia: Negative Symptoms
Definition: Negative symptoms are the absence of things that are normally present. They represent a loss or decrease in normal functions.
Key "A" Symptoms (Memorize these!):
Anhedonia: Lack of pleasure or inability to experience pleasure from activities that once brought enjoyment.
Flat Affect: Lack of emotional expression; a blank or emotionless stare.
Anergia: Lack of energy and drive.
Abolition: Lack of motivation or inability to initiate and persist in goal-directed activities.
Alogia: Poverty of speech; a reduction in the amount or content of speech.
Client Case Study: Initial Assessment and Concerns
Client Presentation: The client's comment about "everyone being devil worshipers" is likely a delusion.
Inability to keep a job: Attributed to the client's negative symptoms.
Lab Result Concerns:
Blood Glucose: Significantly elevated ( \text{very high} ). This requires eventual intervention.
Cholesterol: Elevated. This, combined with elevated blood glucose, raises concern for metabolic syndrome.
Involuntary Admissions and Restraints
Hospital Admission for Patient Safety:
Temporary Emergency Admission (TEA): In Texas, police use an Emergency Detention Order (EDO).
EDO Time Limits: A facility can keep a patient against their will for 48 ext{ hours} during the week and up to 72 ext{ hours} on a weekend. These limits prevent abuse of involuntary admission.
Next Steps When EDO Expires: If the time runs out, the healthcare team has three options:
Release the patient.
Ask the patient to sign in voluntarily.
Obtain a long-term Order of Protective Custody (OPC) for involuntary admission from a judge. This typically requires the patient to be a harm to themselves or others.
Medication Administration: Haldol Example:
Order: Haldol 10 ext{ mg IM} .
On Hand: 2 ext{ mg/mL} .
Volume Calculation: ext{Volume} = rac{ ext{Ordered Dose}}{ ext{Concentration on Hand}} = rac{10 ext{ mg}}{2 ext{ mg/mL}} = 5 ext{ mL} .
Nursing Considerations for 5 ext{ mL} IM: This volume is too large for a single muscle injection, especially the deltoid. Doses would need to be divided across multiple sites (e.g., ventral gluteal). Contacting pharmacy for a higher concentration (e.g., 5 ext{ mg/mL} or 10 ext{ mg/mL} ) is a viable option to reduce the injection volume.
Restraints and Seclusion:
Emergency Use: Can be initiated without an order if necessary for safety, but a physician's order must be obtained within 30 minutes.
Least Restrictive Means: Always a priority. Before restraints, attempt verbal de-escalation and PRN medications.
Physician Assessment: A physician must physically see the patient in restraints/seclusion within 24 hours (or 4 ext{ hours} depending on facility policy).
Monitoring: Continuous observation by paid staff (e.g., documenting every 5 ext{ minutes} ), providing bathroom breaks, and food breaks.
Criteria for Removal: Patient must show decreased agitation, express remorse, and clearly follow commands and directions (e.g., no longer yelling/screaming).
Safe Removal of Four-Point Restraints: Remove one extremity at a time, alternating sides (e.g., right arm, then left leg) to prevent injury to the patient or staff if agitation resumes.
Antipsychotic Medications and Their Side Effects
Neuroleptic Malignant Syndrome (NMS):
Description: A rare, but potentially fatal, adverse reaction to antipsychotics.
Symptoms (Expected in Case Study Scenario):
Extremely elevated vital signs (e.g., BP 188/98 , HR 110 , RR 28 , Temperature 104^ ext{o} ext{F} ).
Diaphoresis (heavy sweating).
Confusion / Decreased Level of Consciousness (LOC).
Muscle rigidity.
Onset: Typically occurs when the patient first starts the medication or has an increase in dosage.
Nursing Actions (ICU Emergency):
Hold the antipsychotic medication immediately and stat page the physician.
Call charge nurse and activate rapid response.
Administer IV acetaminophen.
Apply cooling blankets.
Transfer to ICU.
Administer Dantrolene to stop muscle lysis.
Agranulocytosis (with Clozapine):
Description: A life-threatening decrease in white blood cells (specifically neutrophils), leading to immunosuppression and inability to fight infection.
Medication Association: Can happen with any antipsychotic but is most common with Clozapine (second-generation).
White Blood Cell (WBC) Threshold: If the patient's WBC count is below 3.0 (or 3000 ), hold the medication and call the physician immediately.
Patient/Family Teaching: Crucial to educate on reporting the first signs of infection (e.g., elevated fever, sore throat, cough) due to compromised immune system.
Monitoring: Patients on Clozapine require weekly CBCs initially, then every two weeks, then monthly.
Antipsychotic Generations & Symptom Targeting:
First-Generation Antipsychotics (e.g., Haloperidol):
Target: Primarily positive symptoms (hallucinations, delusions, bizarre behavior, speech alterations).
Mechanism of Action: Mainly affect dopamine.
Second-Generation Antipsychotics (e.g., Clozapine, Risperidone, Olanzapine, Naprazodone):
Target: Both positive and negative symptoms (e.g., flat affect, lack of motivation/energy).
Mechanism of Action: Primarily affect serotonin.
Third-Generation Antipsychotics (e.g., Aripiprazole):
Target: Positive, negative, and can also help with cognitive symptoms.
Olanzapine: Smoking decreases its effectiveness.
Long-Acting Injectables (LAI):
Purpose: Preferred for clients who have difficulty remembering to take oral medications (compliance issues).
Example: Risperidone Consta is an LAI, typically given every two to four weeks (often every three weeks).
Extrapyramidal Symptoms (EPS) and Tardive Dyskinesia (TD):
EPS: Movement disorders (e.g., tremor, rigidity, akathisia) that can occur as a side effect of antipsychotics.
AIMS Scale: The Abnormal Involuntary Movement Scale (AIMS) is used to assess for EPS. Early detection is crucial.
Tardive Dyskinesia: A more severe, sometimes irreversible, form of EPS involving rhythmic, involuntary movements, often affecting the face (e.g., tongue rolling, lip smacking) and trunk.
Treatment for EPS: Benztropine is an anticholinergic medication used to treat EPS. Nurses should advocate for its prescription if EPS is observed.
Benztropine Side Effects (Anticholinergic): "Can't see, can't pee, can't poop" (blurred vision, urinary retention, constipation, dry mouth).
Nursing Interventions for Anticholinergic Side Effects: Increase fluid intake ( 2-3 ext{ L/day} ), suggest sugarless candy/gum (to stimulate saliva), monitor I&Os for urinary retention.
Metabolic Syndrome (General Side Effect of Antipsychotics):
Description: A cluster of conditions (increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels) that increase the risk of heart disease, stroke, and type 2 diabetes.
Implication: Common side effect, especially with second-generation antipsychotics, leading to significant weight gain, elevated blood glucose, A1C, and cholesterol.
Management Strategy: Instead of discontinuing an effective antipsychotic, manage metabolic syndrome with diet modification, exercise, and sometimes medications like Metformin. Newer "two-in-one" antipsychotics combine the antipsychotic with Metformin.
BMI Importance: Knowing the patient's BMI is important to technically identify overweight or obesity.
Abilify MiSight (Aripiprazole):
Description: A third-generation antipsychotic (Aripiprazole) that comes with an ingestible sensor.
Functionality: The sensor sends a signal to a patch worn by the client upon ingestion, which then transmits data to a smartphone app. This system tracks medication adherence for the client and physician.
Cost: Cost-prohibitive for most (over $1000/ ext{month} without insurance, $300/ ext{month} with good insurance); insurance coverage is limited.
Schizophrenia: Classification, Other Causes of Psychosis, and Risk Factors
Schizoaffective Disorder: A client experiences symptoms of schizophrenia and a major mood disorder (e.g., bipolar disorder or major depression).
Brief Psychotic Episode: Psychotic symptoms lasting more than one day but less than 30 ext{ days} .
Other Causes of Psychosis: Not exclusive to schizophrenia; can be caused by acute mania, severe depression, infection, or substance abuse (substance-induced schizophrenia).
Risk Factors for Schizophrenia:
Genetics (strong component).
Environmental factors.
Trauma.
Substance abuse.
Viral infection (some research indicates).
Nutrition (some research indicates).
Schizophrenia: Specific Symptom Details
Hallucinations:
Types:
Auditory (Most Common): Hearing voices or sounds.
Visual: Seeing things that aren't there.
Tactile: Feeling sensations on the skin.
Olfactory: Smelling odors that aren't present.
Most Dangerous: Command Hallucinations, where voices instruct the client to do something.
Assessment for Command Hallucinations: Directly ask, "What are the voices telling you to do?" (Differentiates from suicidal ideation assessment, which asks if the client is having thoughts of harming themselves).
Delusions:
Types:
Grandeur: Belief of possessing great wealth, power, talent, or importance.
Paranoid: Belief that others are trying to harm, stalk, or deceive them (e.g., FBI, CIA).
Thought Withdrawal: Belief that thoughts are being removed from one's mind.
Thought Insertion: Belief that thoughts are being placed into one's mind.
Thought Broadcasting: Belief that one's thoughts are being transmitted for others to hear.
Room Placement for Paranoid Patients: Avoid placing two paranoid patients in the same room, as they can feed into each other's delusions.
Alterations in Speech (Positive Symptoms):
Clanging: Rhyming words (e.g., "box, lock, fox").
Echolalia: Repeating what someone else says (e.g., Nurse: "Hi, Mr. Jones, how are you today?" Patient: "Hi, Mr. Jones, how are you today?").
Neologisms: Making up new words that have meaning only to the client.
Word Salad: Jumbling words into an incomprehensible sentence, although the individual words are real.
Bizarre Behavior / Alterations in Movement (Positive Symptoms):
Echopraxia: Imitating others' movements.
Waxy Flexibility: Maintaining a fixed body position for extended periods (hours) despite physical discomfort. This is a form of catatonia.
Catatonia: A state of unresponsiveness or stupor, often associated with waxy flexibility.
Nursing Concerns with Waxy Flexibility/Catatonia: Risk for pressure injuries, decreased circulation, muscle mass loss, contractures (requiring physical therapy/ROM exercises), dehydration, and malnutrition (may need assistance with feeding).
Dementia: Overview
Types of Dementia:
Alzheimer's Type (Most Common).
Vascular Dementia (formerly post-stroke dementia).
Lewy Body Dementia (abnormal protein deposits in the brain).
Frontotemporal Lobe Dementia.
Alzheimer's Confirmation: Can only be officially confirmed upon autopsy after death by observing increased amyloid plaques and neurofibrillary tangles in the brain.
Diagnostics: Performed to rule out other causes of memory issues (e.g., CT scan, MRI, blood work), not to diagnose Alzheimer's directly.
Dementia: Symptoms and Defense Mechanisms
Symptoms:
Loss of short-term memory (key characteristic - may remember 1950 but not what they ate yesterday).
Decreased attention span.
Problems recalling words and names.
Increased irritability.
Decreased ability to perform Activities of Daily Living (ADLs).
Occupational Therapy (OT): Important in early stages to reinforce ADL skills.
Physical Therapy (PT): Helps maintain muscle mass.
Defense Mechanisms (Important for Family Education):
Denial: Both the client and family may deny the presence of the disorder.
Confabulation: The unconscious creation of untrue stories or details to fill in memory gaps, preserving self-esteem. The client believes their fabricated stories.
Perseveration: Repeating an answer or statement, or avoiding a question by redirecting to a known fact, despite not knowing the requested information (e.g., asked about dinner, answers about wanting mac and cheese today).
Mimics of Dementia: Depression, especially in the elderly, can mimic dementia symptoms.
Dementia: Safety and Screening
Safety Issues (Especially in Later Stages):
Malnutrition/Dehydration.
Wandering (risk of leaving the house).
Increased risk for falls (remove carpets/rugs, secure cords, consider putting mattress on floor, move downstairs in multi-story homes).
Water heater temperature (prevent burns).
Lock up cleaning supplies.
Prevent cooking alone (forgetting stove is on).
Proper home locks to prevent wandering.
Screening Tools:
Mini-Mental Status Exam (MMSE).
Functional Assessment Tool.
Geriatric Depression Scale.
Confusion Assessment Method (CAM).
BLESS Dementia Scale: Unique because it's based on family responses (interviewing family members) rather than directly assessing the client.
Dementia: Management and Medications
Non-Pharmacological Interventions:
Support Groups: Encourage families to seek support for living with loved ones with dementia.
Respite Care: Provides temporary relief for family caregivers, allowing them a break while ensuring the loved one receives professional nursing care, often covered by insurance for specific timeframes.
Medications (Aim to Slow Progression, Not Cure):
Cholinesterase Inhibitors:
Examples: Donepezil, Rivastigmine.
Stage: Effective in early stages of Alzheimer's.
Rivastigmine: Available as a patch, which is beneficial for patients with difficulty swallowing pills.
Nursing Considerations: Start low, go slow. Monitor heart rate, orthostatic hypotension (fall risk), and I&Os for urinary retention.
Memantine:
Mechanism: Slows down brain cell death by affecting calcium.
Significance: The only medication mentioned with this specific mechanism of action for dementia.