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All information and pictures presented in this slideshow were meant for EDUCATIONAL purposes only. 1Nurses.com does not claim any liability from the use of this slide and does not guarantee any action that might result from the use of this material. 1Nurses.com does not claim any ownership for the images and articles presented in this report. All articles and Images are the respective Copyright of the respective owners.

“ The ability to think and to reason is one of the distinguishing features of a human being”

“ The ability to think and to reason is one of the distinguishing features of a human being”

COGNITION Is the brain’s ability to process, retain and use information.

Is the brain’s ability to process, retain and use information.

COGNITIVE ABILITIES P erception O rientation R easoning M emory A ttention

P erception

O rientation

R easoning

M emory

A ttention

COGNITIVE DISORDER Delirium Dementia Amnestic disorder Other cognitive disorder

Delirium

Dementia

Amnestic disorder

Other cognitive disorder

DELIRIUM “ acute confusional state” Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition. Develops over a short period , sometimes a matter of hours and fluctuates or changes during the course of the day.

“ acute confusional state”

Is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition.

Develops over a short period , sometimes a matter of hours and fluctuates or changes during the course of the day.

DSM CRITERIA for DELIRIUM Disturbances of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus or sustain or shift attention. Change in cognition (such as memory deficit, disorientation, language disturbance, perceptual disturbance) Development over a short period of time (usually hours to days) and with a tendency to fluctuate during the course of the day.

Disturbances of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus or sustain or shift attention.

Change in cognition (such as memory deficit, disorientation, language disturbance, perceptual disturbance)

Development over a short period of time (usually hours to days) and with a tendency to fluctuate during the course of the day.

KEY SYMPTOMS OF DELIRIUM F EARFULNESS D ISORIENTATION A GITATION

F EARFULNESS

D ISORIENTATION

A GITATION

ETIOLOGY: UNKNOWN General Medical condition CHF, Pneumonia, Uremia, Malnutrition, dehydration, cancer, CVA and etc. Substance Prescription drug intoxication like anticholinergic drugs combination (elavil, antihistamines, antispasmodics, analgesics, steroids, sedatives, cardiovascular drugs (digoxin and diuretics) and cimetidine.)

UNKNOWN

General Medical condition

CHF, Pneumonia, Uremia, Malnutrition, dehydration, cancer, CVA and etc.

Substance

Prescription drug intoxication like anticholinergic drugs combination (elavil, antihistamines, antispasmodics, analgesics, steroids, sedatives, cardiovascular drugs (digoxin and diuretics) and cimetidine.)

MANAGEMENT: Treatment of underlying disease and judicious use of medications and manipulation of the environment. Symptomatic relief through supportive therapy Good nutrition Hydration Rest Comfort measures Emotional support

Treatment of underlying disease and judicious use of medications and manipulation of the environment.

Symptomatic relief through supportive therapy

Good nutrition

Hydration

Rest

Comfort measures

Emotional support

Psychopharmacology Hypoactive delirium – no specific meds Hyperactive – sedation Haloperidol (.5 to 1mg) NO benzodiazepine Except if caused by alcohol – benzo Restraints

Hypoactive delirium – no specific meds

Hyperactive – sedation

Haloperidol (.5 to 1mg)

NO benzodiazepine

Except if caused by alcohol – benzo

Restraints

APPLICATION OF THE NURSING PROCESS Nursing care focus: Physiologic and psychological needs Safety

Nursing care focus:

Physiologic and psychological needs

Safety

Assessment History Medical illness Alcohol and other drugs

History

Medical illness

Alcohol and other drugs

General Appearance Psychomotor disturbances Hyperactive Hypoactive Speech Less coherent

Psychomotor disturbances

Hyperactive

Hypoactive

Speech

Less coherent

Mood and Affect Rapid and unpredictable mood shifts Fearfulness, anger, euphoria, apathy, irritability, anxiety. No connection to the environment.

Rapid and unpredictable mood shifts

Fearfulness, anger, euphoria, apathy, irritability, anxiety.

No connection to the environment.

Sensorium and Intellectual processes Altered LOC – Initial sign , fluctuates through out the day. Oriented to person but disoriented to time and place Impaired recent memory Alteration in Perception

Altered LOC – Initial sign , fluctuates through out the day.

Oriented to person but disoriented to time and place

Impaired recent memory

Alteration in Perception

Insight and Judgment Mild Aware Severe No insight to the situation

Mild

Aware

Severe

No insight to the situation

Physiologic and Self care Disturbed Sleep – Wake cycle

Disturbed Sleep – Wake cycle

Diagnosis Primary Risk for Injury Acute confusion Additional Disturbed Sensory Perception Disturbed Thought Process Disturbed Sleeping Pattern

Primary

Risk for Injury

Acute confusion

Additional

Disturbed Sensory Perception

Disturbed Thought Process

Disturbed Sleeping Pattern

INTERVENTION Promoting Clients Safety Meds should be used judiciously Teach the client to ask assistance if not close supervision Managing Confusion Give realistic Reassurance “ I know things are upsetting and confusing to you right now, but your confusion should clear as you get better.”

Promoting Clients Safety

Meds should be used judiciously

Teach the client to ask assistance if not close supervision

Managing Confusion

Give realistic Reassurance

“ I know things are upsetting and confusing to you right now, but your confusion should clear as you get better.”

Speak in short. Simple, clear, low voice Orienting cues Touch Reduce Environmental Stimuli Well lighted room Promoting Sleep and Proper Nutrition

Speak in short. Simple, clear, low voice

Orienting cues

Touch

Reduce Environmental Stimuli

Well lighted room

Promoting Sleep and Proper Nutrition

Evaluation Returns to their previous level of functioning Understands that health care practices are necessary to avoid recurrence

Returns to their previous level of functioning

Understands that health care practices are necessary to avoid recurrence

DEMENTIA Is a complex and devastating problem that is a major cause of disability in the older adult population. It is not a normal aging process Is characterized by the development of multiple cognitive deficits and usually accompanied by mood disturbances. Course is GRADUAL in onset with an unabated cognitive decline. The symptoms of dementia remain even delirium has cleared.

Is a complex and devastating problem that is a major cause of disability in the older adult population.

It is not a normal aging process

Is characterized by the development of multiple cognitive deficits and usually accompanied by mood disturbances.

Course is GRADUAL in onset with an unabated cognitive decline.

The symptoms of dementia remain even delirium has cleared.

DSM CRITERIA for DEMENTIA Multiple Cognitive deficits: Memory impairment (amnesia) At least one of the following cognitive disturbances: Aphasia Apraxia Agnosia Disturbance In executive functioning (PLOC) Significant impairment in social or occupational functioning.

Multiple Cognitive deficits:

Memory impairment (amnesia)

At least one of the following cognitive disturbances:

Aphasia

Apraxia

Agnosia

Disturbance In executive functioning (PLOC)

Significant impairment in social or occupational functioning.

Amnesia Early sign Initially RECENT memory and in later stages it affects REMOTE memory

Early sign

Initially RECENT memory and in later stages it affects REMOTE memory

Aphasia Deterioration of language function. Begins with the inability to name familiar objects or people then progress to speech that becomes vague or empty with excessive use of “ It ” and “ Thing ” Echolalia and Palilalia

Deterioration of language function.

Begins with the inability to name familiar objects or people then progress to speech that becomes vague or empty with excessive use of “ It ” and “ Thing ”

Echolalia and Palilalia

Apraxia Impaired ability to execute motor functions despite intact motor abilities. Inability to perform routine self care activities

Impaired ability to execute motor functions despite intact motor abilities.

Inability to perform routine self care activities

Agnosia Inability to recognize or name objects despite intact sensory abilities. They may look at the table and chairs but unable to name them.

Inability to recognize or name objects despite intact sensory abilities.

They may look at the table and chairs but unable to name them.

ONSET & CLINICAL COURSE MILD Forgetfulness – hallmark sign Difficulty finding words Frequently loses objects – anxiety Occupational and Social settings are less enjoyable Most people remain in the community

MILD

Forgetfulness – hallmark sign

Difficulty finding words

Frequently loses objects – anxiety

Occupational and Social settings are less enjoyable

Most people remain in the community

MODERATE Confusion is apparent with progressive memory loss No longer perform complex task but remains oriented to PPT End stage Loses the ability to live independently Remains in the community but with caregiver

MODERATE

Confusion is apparent with progressive memory loss

No longer perform complex task but remains oriented to PPT

End stage

Loses the ability to live independently

Remains in the community but with caregiver

SEVERE Personality and Emotional changes occur Delusional, wander at night, forget the names of his or her spouse and children. Requires assistance in ADL Lives in Nursing Facility

SEVERE

Personality and Emotional changes occur

Delusional, wander at night, forget the names of his or her spouse and children.

Requires assistance in ADL

Lives in Nursing Facility

ETIOLOGY: Vascular injury Degenerative disease Neoplastic Demyelinating disease Infectious Inflammatory Toxic Metabolic

Vascular injury

Degenerative disease

Neoplastic

Demyelinating disease

Infectious

Inflammatory

Toxic

Metabolic

APPLICATION OF THE NURSING PROCESS

Assessment Folstein Mini Mental State examination (MMSE) Administered in 5 to 10 minutes Consists of variety of questions that cover the memory, orientation, attention, constructional abilities. Interviews of family, friends or caregivers

Folstein Mini Mental State examination (MMSE)

Administered in 5 to 10 minutes

Consists of variety of questions that cover the memory, orientation, attention, constructional abilities.

Interviews of family, friends or caregivers

Mood and Affect Anxiety and Fear at first Labile mood Catastrophic emotional reactions in response to environmental changes Verbal or physical aggression Wandering at night Agitation Withdrawn

Anxiety and Fear at first

Labile mood

Catastrophic emotional reactions in response to environmental changes

Verbal or physical aggression

Wandering at night

Agitation

Withdrawn

Thought Process and Content Ability to think abstractly is impaired As dementia progresses Delusion of Persecution is common The client may accuse others of stealing objects he or she has lost May believe that she is being cheated or pursued

Ability to think abstractly is impaired

As dementia progresses

Delusion of Persecution is common

The client may accuse others of stealing objects he or she has lost

May believe that she is being cheated or pursued

Sensorium and Intellectual Process Recent – Remote Confabulation Visual Hallucination

Recent – Remote

Confabulation

Visual Hallucination

Physiologic and Self Care Disturbed sleep – wake cycle Nap during the day and wanders at night Some clients ignore internal cues like hunger or thirst or difficulty eating and drinking (severe) Neglect bathing and grooming

Disturbed sleep – wake cycle

Nap during the day and wanders at night

Some clients ignore internal cues like hunger or thirst or difficulty eating and drinking (severe)

Neglect bathing and grooming

Diagnosis Risk for Injury Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition Chronic Confusion Impaired Environmental Interpretation Syndrome Impaired Memory Impaired Social Interaction Impaired Verbal Communication Ineffective Role Performance

Risk for Injury

Risk for Deficient Fluid Volume

Risk for Imbalanced Nutrition

Chronic Confusion

Impaired Environmental Interpretation Syndrome

Impaired Memory

Impaired Social Interaction

Impaired Verbal Communication

Ineffective Role Performance

Intervention Focus on demonstrating caring, keeping clients involved by relating to the environment

Focus on demonstrating caring, keeping clients involved by relating to the environment

Promoting Client’s Safety Protecting against injury Meeting physiologic needs Managing the risk posed by the environment including internal stimuli such as Delusion and Hallucination

Promoting Client’s Safety

Protecting against injury

Meeting physiologic needs

Managing the risk posed by the environment including internal stimuli such as Delusion and Hallucination

Promoting Adequate Sleep and Proper nutrition, hygiene and activity Provide foods that clients like Sitting with the client Nutritious snacks Minimizing noise Foods should be cut Finger foods Tube Feedings Monitor bowel elimination Urinary Pattern Balance between rest and activity

Promoting Adequate Sleep and Proper nutrition, hygiene and activity

Provide foods that clients like

Sitting with the client

Nutritious snacks

Minimizing noise

Foods should be cut

Finger foods

Tube Feedings

Monitor bowel elimination

Urinary Pattern

Balance between rest and activity

Structured Environment and Routine Client’s preference Emotional Support Empathic caring Supportive Touch

Structured Environment and Routine

Client’s preference

Emotional Support

Empathic caring

Supportive Touch

Promoting Interaction and Involvement Reminiscence Therapy Thinking about or relating personally significant past experiences Photo albums Distraction Time away (5 – 10 mins.) Going Along Providing emotional reassurance

Promoting Interaction and Involvement

Reminiscence Therapy

Thinking about or relating personally significant past experiences

Photo albums

Distraction

Time away (5 – 10 mins.)

Going Along

Providing emotional reassurance

DELIRIUM DEMENTIA Onset Acute, often at night Insidious Course Fluctuating , with lucid intervals, during day: worse at night Stable over course of the day Duration Hours to week Months to years

Awareness Reduced Clear Alertness Abnormally LOW or HIGH Usually Normal Attention Lacks direction and selectivity; distractibility; fluctuates over course of the day Relatively unaffected Orientation Usually impaired for time; tendency to mistake unfamiliar to familiar place and persons Often impaired

Memory Immediate and recent memory impairments Recent and remote memory impairments – the most prominent symptom Thinking Disorganized Impoverished Perception Illusions and Hallucinations (usually visual) Often absent Sometimes: Hallucinations Delusions Illusions

Speech Incoherent, hesitant, slow or rapid Difficulty finding words Sleep wake cycle Always disrupted Fragmented sleep Physical Illness or Drug toxicity Either or both present Often absent, especially in Alzheimer’s type

Reversible Dementia SLE (encephalopathy) Syphilis Alcohol abuse Hypo and Hyperthyroidism B12 and folate deficiency

SLE (encephalopathy)

Syphilis

Alcohol abuse

Hypo and Hyperthyroidism

B12 and folate deficiency

Non Reversible Dementia Alzheimer’s Disease Parkinson’s disease Pick’s disease Creutzfeldt Jakob Disease Vascular or multiinfarct dementia Alcoholic Dementia TIA

Alzheimer’s Disease

Parkinson’s disease

Pick’s disease

Creutzfeldt Jakob Disease

Vascular or multiinfarct dementia

Alcoholic Dementia

TIA

ALZHEIMER’S DISEASE Commonly seen in the elderly ( 65 years old) Most prevalent of all non reversible dementia (50 – 75%) Age related progressive disorder of the CNS Alois Alzheimer , post mortem revealed brain atrophy and distortions in the cortical neurofibrils = ALZHEIMER’S TANGLE or Neurofibrillary tangles

Commonly seen in the elderly ( 65 years old)

Most prevalent of all non reversible dementia (50 – 75%)

Age related progressive disorder of the CNS

Alois Alzheimer , post mortem revealed brain atrophy and distortions in the cortical neurofibrils = ALZHEIMER’S TANGLE or Neurofibrillary tangles

4A’s mnesia gnosia praxia phasia A

mnesia

gnosia praxia

phasia

ETIOLOGY: UNKNOWN Presence of senile plaques and NFT Dystrophic neuritis; thickened swollen neuronal process Abnormal amyloid deposits within the senile plaques and around the blood vessels Genetics Toxins Aluminum Infection Slow growing virus Cholinergic deficit Loss of cholinergic neurons in the brain(nucleus basalis of meynert) Reduction in Acetylcholine

UNKNOWN

Presence of senile plaques and NFT

Dystrophic neuritis; thickened swollen neuronal process

Abnormal amyloid deposits within the senile plaques and around the blood vessels

Genetics

Toxins

Aluminum

Infection

Slow growing virus

Cholinergic deficit

Loss of cholinergic neurons in the brain(nucleus basalis of meynert)

Reduction in Acetylcholine

Impairment In ADL based on stages of AD

Mild Difficulty with Balancing checkbook Preparing complex meal Managing medication schedule

Difficulty with

Balancing checkbook

Preparing complex meal

Managing medication schedule

Moderate Difficulty with Simple food preparation Household clean up Yardwork Some aspects of self care

Difficulty with

Simple food preparation

Household clean up

Yardwork

Some aspects of self care

Severe Needs considerable assistance with Personal care Feeding Grooming Toileting

Needs considerable assistance with

Personal care

Feeding

Grooming

Toileting

Profound Oblivious to surrounding and totally dependent to the caregiver

Oblivious to surrounding and totally dependent to the caregiver

Terminal Bed bound, requiring constant care

Bed bound, requiring constant care

TREATMENT Donezepil (Aricept) od Tacrine (Cognex) qid Rivastigmine Galantamine Ginkgo Biloba NSAID’s Vitamin E Estrogen Calcium Channel Blockers prevents influx

Donezepil (Aricept) od

Tacrine (Cognex) qid

Rivastigmine

Galantamine

Ginkgo Biloba

NSAID’s

Vitamin E

Estrogen

Calcium Channel Blockers prevents influx

PARKINSON’S DISEASE A hypokinetic disorder , is a progressive, chronic, degenerative disease involving an area in the brain called the EPS ETIOLOGY: deficiency of the DOPAMINE and a subsequent decrease in the DOPAMINE transmission to the basal ganglia. S/Sx: BTR

A hypokinetic disorder , is a progressive, chronic, degenerative disease involving an area in the brain called the EPS

ETIOLOGY: deficiency of the DOPAMINE and a subsequent decrease in the DOPAMINE transmission to the basal ganglia.

S/Sx: BTR

DIFFUSE LEWY BODY DISEASE Similar to AD but typically occurs in earlier life and is associated more often with Hallucination and Extra Pyramidal Symptoms Evolves rapidly Pathological feature: Presence of multiple Lewy bodies (eosinophilic cytoplasmic inclusions) in cortical and subcortical neurons.

Similar to AD but typically occurs in earlier life and is associated more often with Hallucination and Extra Pyramidal Symptoms

Evolves rapidly

Pathological feature: Presence of multiple Lewy bodies (eosinophilic cytoplasmic inclusions) in cortical and subcortical neurons.

HUNTINGTON’S DISEASE (huntington’s Chorea) Involves both motor and cognitive disorder Kinetic opposite of PD Characterized by uncontrollable quick, jerky and purposeless writhing movements. Disturbance in gait and slurred speech are noted in the beginning and progress into neurological and intellectual deterioration. Memory loss, paranoia, irritability, impaired impulse control and lack of tongue and breathing control. Usually begins between the ages 25 to 45 average duration of 15 to 20 years Hereditary Symptomatic approach

Involves both motor and cognitive disorder

Kinetic opposite of PD

Characterized by uncontrollable quick, jerky and purposeless writhing movements.

Disturbance in gait and slurred speech are noted in the beginning and progress into neurological and intellectual deterioration.

Memory loss, paranoia, irritability, impaired impulse control and lack of tongue and breathing control.

Usually begins between the ages 25 to 45 average duration of 15 to 20 years

Hereditary

Symptomatic approach

PICKS’S DISEASE Clinical presentation is similar to AD and are usually treated in the same way. Associated with aging and is without race and gender basis Onset is slow with an average duration of 5 to 7 years. Characterized by shrinkage of the frontal lobe.

Clinical presentation is similar to AD and are usually treated in the same way.

Associated with aging and is without race and gender basis

Onset is slow with an average duration of 5 to 7 years.

Characterized by shrinkage of the frontal lobe.

CREUTZFELDT – JAKOB DISEASE Also known as “Prion disease” Is a non inflammatory dementia that accounts for fewer than 1% of all cases of dementia. Prion is an infectious particle, smaller than a virus. It is rapidly progressive disorder of the CNS involving severe neurological impairment with marked dysfunction. Affects the cerebral cortex Early symptoms are vision and hearing loss, impaired cognition, myoclonus, ataxia, muscle wasting, tremor, hallucinations and illusions.

Also known as “Prion disease”

Is a non inflammatory dementia that accounts for fewer than 1% of all cases of dementia.

Prion is an infectious particle, smaller than a virus.

It is rapidly progressive disorder of the CNS involving severe neurological impairment with marked dysfunction.

Affects the cerebral cortex

Early symptoms are vision and hearing loss, impaired cognition, myoclonus, ataxia, muscle wasting, tremor, hallucinations and illusions.

VASCULAR OR MULTI INFARCT DEMENTIA Multiple large and small cerebral infarcts. CV disease maybe the leading cause of acquired intellectual impairment in the age 85 and older population.

Multiple large and small cerebral infarcts.

CV disease maybe the leading cause of acquired intellectual impairment in the age 85 and older population.

ALCOHOLIC DEMENTIA Typically occurs 15 to 20 years of continues drinking. Alcoholic dementia has three primary symptoms: Alcohol is directly toxic to the neurons Alcoholism causes destructive nutritional deficit Alcoholism causes end organ failure which in turn affects the CNS.

Typically occurs 15 to 20 years of continues drinking.

Alcoholic dementia has three primary symptoms:

Alcohol is directly toxic to the neurons

Alcoholism causes destructive nutritional deficit

Alcoholism causes end organ failure which in turn affects the CNS.

TRANSIENT ISCHEMIC ATTACKS The chief importance of TIA is a precursor of a major stroke, MI or death. The syndrome is caused by microembolism to the brain from atherosclerotic plaques in the aortocranial arteries in about 90% of TIA. 10 % for mural thrombi, valvular disease of the heart, vegetation of the heart valve, polycythemia, or some other blood clotting disorder.

The chief importance of TIA is a precursor of a major stroke, MI or death.

The syndrome is caused by microembolism to the brain from atherosclerotic plaques in the aortocranial arteries in about 90% of TIA. 10 % for mural thrombi, valvular disease of the heart, vegetation of the heart valve, polycythemia, or some other blood clotting disorder.

PSYCHOTHERAPEUTIC MANAGEMENT

TNPR Delirium HIGHEST PRIORITY : interventions to maintain life Dementia HIGHEST PRIORITY : Providing Nursing Care to maintain optimal level of functioning Must learn the background and lifestyle of the patient. One on One basis by using the title and last name. Use praise, touch and affection whenever possible. Should be dressed in his or her own clothing during the day with his or her hair combed. Make up, shaved. Safety

Delirium HIGHEST PRIORITY : interventions to maintain life

Dementia HIGHEST PRIORITY : Providing Nursing Care to maintain optimal level of functioning

Must learn the background and lifestyle of the patient.

One on One basis by using the title and last name.

Use praise, touch and affection whenever possible.

Should be dressed in his or her own clothing during the day with his or her hair combed. Make up, shaved.

Safety

PSYCHOPHARMACOLOGY Antipsychotics Antidepressants Antianxiety

Antipsychotics

Antidepressants

Antianxiety

MILIEU They should be in the safe environment free from injury, stress and anxiety. Warm caring atmosphere Routine the patient can follow daily Close supervision during bathing, eating and other activities. All sharps or hazardous materials should be removed, The doors should be monitored to prevent escape.

They should be in the safe environment free from injury, stress and anxiety.

Warm caring atmosphere

Routine the patient can follow daily

Close supervision during bathing, eating and other activities.

All sharps or hazardous materials should be removed,

The doors should be monitored to prevent escape.

3 milieu related issues STRESS – cause of anxious behavior The work of HALL “Progressively Lowered Stress Threshold” (PLST) Stressors includes: Fatigue Change of routine Excessive demands Overwhelming stimuli Physical stressors SAFETY WANDERING

STRESS – cause of anxious behavior

The work of HALL “Progressively Lowered Stress Threshold” (PLST)

Stressors includes:

Fatigue

Change of routine

Excessive demands

Overwhelming stimuli

Physical stressors

SAFETY

WANDERING

CBQ Nursing Management Never Change the environment Don’t educate new skills olor lock alendar C

Nursing Management

Never Change the environment

Don’t educate new skills

olor

lock

alendar

Ginko Biloba – delays AD SE: Bleeding Etiology: Unknown, ACH, Senile plaques, Aluminum Toxicity

Ginko Biloba – delays AD

SE: Bleeding

Etiology: Unknown, ACH, Senile plaques, Aluminum Toxicity

3 stages Forgetfulness Agnosia, amnesia Wandering Sundown syndrome – restless and anxiety Management: Avoid catnap, coffee, increase fluid, diuretics Medical bracelet Warm bath, warm milk DOC: Serax and Ativan Kleuver Bucy like syndrome Decrease social and sexual inhibition Hyperorality - REGRESSION

Forgetfulness

Agnosia, amnesia

Wandering

Sundown syndrome – restless and anxiety

Management:

Avoid catnap, coffee, increase fluid, diuretics

Medical bracelet

Warm bath, warm milk

DOC: Serax and Ativan

Kleuver Bucy like syndrome

Decrease social and sexual inhibition

Hyperorality - REGRESSION

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