Cognitive disorders behavior therapy ect

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Cognitive disorders behavior therapy ect

  1. 1. Cognitive Disorders ECT Phyllis M. Connolly, PhD, RN, CS NURS 127A
  2. 2. Questions for consideration <ul><li>What are the similarities and differences between delirium, dementia, and depression? </li></ul><ul><li>What is a catastropic reaction and what interventions are helpful? </li></ul><ul><li>What is a positive client outcome for altered thought processes? </li></ul><ul><li>What the indications for ECT? </li></ul>
  3. 3. Cognitive Impairments <ul><li>2.4 million Americans suffer from dementing illnesses </li></ul><ul><li>7.3 million by 2040 </li></ul><ul><li>Alzheimer’s Disease </li></ul><ul><li>Dementias </li></ul><ul><ul><li>Vascular--interruption of blood flow to brain </li></ul></ul><ul><ul><li>Parkinson’s--involves extrapyramidal </li></ul></ul><ul><ul><li>Diffuse Lewy Body Disease </li></ul></ul><ul><ul><li>Huntington’s Disease </li></ul></ul><ul><li>Creutzfeldt-Jakob Disease </li></ul><ul><li>Alcoholic Dementia </li></ul><ul><li>TIA </li></ul>
  4. 4. Medications Causing or Contributing to Dementia or Delirium <ul><li>Analgesics </li></ul><ul><ul><li>Codeine </li></ul></ul><ul><ul><li>Meperidine </li></ul></ul><ul><ul><li>Morphine </li></ul></ul><ul><ul><li>Pentzcocine </li></ul></ul><ul><ul><li>Indomethacin </li></ul></ul><ul><li>Antihistamines </li></ul><ul><ul><li>Dephenhydramine </li></ul></ul><ul><ul><li>Hydroxyzine </li></ul></ul><ul><li>Antihypertensives </li></ul><ul><ul><li>Clonidine </li></ul></ul><ul><ul><li>Hydralazine </li></ul></ul><ul><ul><li>Methyldopa </li></ul></ul><ul><ul><li>Propranolol </li></ul></ul><ul><ul><li>Reserpine </li></ul></ul><ul><li>Antimicrobials </li></ul><ul><ul><li>Gentamicin </li></ul></ul><ul><ul><li>Isoniazid </li></ul></ul>
  5. 5. Medications Causing or Contributing to Dementia or Delirium Cont. <ul><li>Antiparkinsonism </li></ul><ul><ul><li>Amantadine </li></ul></ul><ul><ul><li>Bromocriptine </li></ul></ul><ul><ul><li>Carbidopa </li></ul></ul><ul><ul><li>L-Dopa </li></ul></ul><ul><li>Cardiovascular </li></ul><ul><ul><li>Atorpine </li></ul></ul><ul><ul><li>Digitalis </li></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><li>Lidocaine </li></ul></ul><ul><li>Hypoglycemics </li></ul><ul><ul><li>Insulin </li></ul></ul><ul><ul><li>Sulfonyureas </li></ul></ul><ul><li>Psychotropics </li></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><li>Lithium </li></ul></ul><ul><ul><li>Tricyclics </li></ul></ul><ul><ul><li>Haloperidol </li></ul></ul><ul><ul><li>Thiothixene </li></ul></ul><ul><ul><li>Chlorpromazine </li></ul></ul><ul><ul><li>Barbituates </li></ul></ul><ul><ul><li>Chloral hydrate </li></ul></ul><ul><li>Others </li></ul><ul><ul><li>Cimetidine </li></ul></ul><ul><ul><li>Steroids </li></ul></ul><ul><ul><li>Trihexyphenidyl & other anticholinergics </li></ul></ul>
  6. 6. Dementia <ul><li>Constellation of symptoms resulting in impairment of short and long term memory </li></ul><ul><li>Onset slow or insidious </li></ul><ul><li>Progressive ends in death </li></ul><ul><li>Deterioration in judgment & abstract reasoning </li></ul><ul><li>Social & occupational functioning significantly affected </li></ul><ul><li>Most common cause Alzheimer’s </li></ul>
  7. 7. Four As of Alzheimer’s Disease <ul><li>Amnesia--inability to learn new information or to recall previously learned information </li></ul><ul><li>Agnosia--failure to recognize or identify objects despite intact sensory function </li></ul><ul><li>Aphasia--language disturbance that manifest in both understanding & expressing the spoken word </li></ul><ul><li>Apraxia--inability to carry out motor activities despite intact motor function </li></ul>
  8. 8. Alzheimer’s: Etiology <ul><li>Senile plaques & neurofibrillary tangles </li></ul><ul><li>Dystrophic neurites(thickened, swollen neuronal processes) </li></ul><ul><li>Abnormal amyloid deposits </li></ul><ul><li>Genetic--10-15% of cases </li></ul><ul><li>Toxin model--aluminum salts </li></ul><ul><li>Infectious agent model--virus </li></ul><ul><li>Cholinergic deficit model </li></ul>
  9. 9. Alzheimer’s Disease: Behavioral Symptoms <ul><li>Hallucinations </li></ul><ul><li>Delusions </li></ul><ul><li>Dysphoria & depression </li></ul><ul><li>Fearfulness </li></ul><ul><li>Repetitive purposeless acts </li></ul><ul><li>Avoidance behavior </li></ul><ul><li>Motor restlessness </li></ul><ul><li>Apathy </li></ul><ul><li>Verbal and physical aggression </li></ul><ul><li>Resistance to interventions </li></ul><ul><ul><li>Hygiene </li></ul></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Safety </li></ul></ul>
  10. 10. Stressors for Persons with Cognitive Impairments <ul><li>Fatigue </li></ul><ul><li>Change of environment, routine or caregiver </li></ul><ul><li>Overwhelming or competing stimuli </li></ul><ul><li>Demands that exceed capacity to function </li></ul><ul><li>Physical stressors </li></ul>
  11. 11. Catastropic Reaction <ul><li>Excessive distress exhibited by patients in situations that are confusing or frightening ex. Showering </li></ul><ul><li>Interventions </li></ul><ul><ul><li>Remain calm </li></ul></ul><ul><ul><li>Remove patient from whatever is upsetting </li></ul></ul><ul><ul><li>Use distraction rather than confrontation </li></ul></ul>
  12. 12. Impaired Cognitive Functioning <ul><li>Key Elements of Care </li></ul><ul><ul><li>Communication </li></ul></ul><ul><ul><li>Orientation </li></ul></ul><ul><ul><li>Structure </li></ul></ul><ul><ul><li>Stimulation </li></ul></ul><ul><ul><li>Safety </li></ul></ul>
  13. 13. Altered Thought Processes <ul><li>Client Outcomes </li></ul><ul><ul><li>Demonstrates improved reality orientation </li></ul></ul><ul><ul><li>Responds coherently to simple requests </li></ul></ul><ul><ul><li>Follows simple directions </li></ul></ul><ul><li>Interventions </li></ul><ul><ul><li>Baseline mental status & functioning </li></ul></ul><ul><ul><li>Avoid making demands </li></ul></ul><ul><ul><li>Ask only one question & make only one request at a time </li></ul></ul><ul><ul><li>Provide a structured routine </li></ul></ul><ul><ul><li>Provide familiar objects </li></ul></ul><ul><ul><li>Avoid agreeing with confused thinking but DO NOT ARGUE--try to distract </li></ul></ul><ul><ul><li>Incorporate orientation cues from the environment </li></ul></ul><ul><ul><li>Keep environment simple & uncluttered </li></ul></ul>
  14. 14. Delirium <ul><li>Alterations in consciousness </li></ul><ul><li>Changes in cognition </li></ul><ul><li>Usually caused by medical condition or substance induced </li></ul><ul><li>Develop over short period of time </li></ul><ul><li>Treatable </li></ul><ul><li>30% CCU environments, “CCU psychosis” </li></ul><ul><li>Disoriented </li></ul><ul><li>Disorganized thinking and speech </li></ul><ul><li>Altered perceptions: illusions, delusions & hallucinations </li></ul><ul><li>EEG changes </li></ul><ul><li>Neurological abnormalities </li></ul>
  15. 15. Delirium: Treatment <ul><li>Identify & correct cause </li></ul><ul><ul><li>anemia </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><ul><li>nutritional deficiencies </li></ul></ul><ul><ul><li>electrolyte imbalance </li></ul></ul><ul><li>Monitor closely </li></ul><ul><li>Safety high priority </li></ul><ul><li>Control behavioral symptoms </li></ul><ul><li>Well lighted room, visible clock & calendar </li></ul>
  16. 16. Comparison Dementia, Delirium & Depression
  17. 17. Psychotherapeutic Management <ul><li>Nurse-Patient Relationship </li></ul><ul><li>Psychopharmacology </li></ul><ul><ul><li>Antipsychotics </li></ul></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><li>Antianxiety </li></ul></ul><ul><ul><li>Treatment of cognitive impairment </li></ul></ul><ul><ul><ul><li>cholinergic enhancers </li></ul></ul></ul><ul><ul><ul><li>metabolic enhancers/vasodilators </li></ul></ul></ul><ul><ul><ul><li>Nootropic agents </li></ul></ul></ul><ul><ul><li>Milieu management </li></ul></ul><ul><ul><ul><li>Safety </li></ul></ul></ul>
  18. 18. Validation Therapy <ul><li>Enter client’s world rather than force to relate to an external world which is no longer comprehensible </li></ul><ul><li>Increase the client’s sense of being understood by others </li></ul><ul><li>Reduces agitation and catastrophic reaction </li></ul><ul><li> quality of life </li></ul>Schober, Glod, Jones, 1998, p .252
  19. 19. Tips for Working with Persons with Dementia <ul><li>Person wears identification bracelet </li></ul><ul><li>Install special locks, safety devices on doors, stove & other potentially dangerous objects </li></ul><ul><li>Check frequently for burns, bruises, or abrasions </li></ul><ul><li>Assess for signs of abuse </li></ul><ul><li>Only use restraints after other methods are ineffective--need MD order </li></ul><ul><li>Look directly at person when speaking </li></ul><ul><li>Identify yourself prior to interaction </li></ul><ul><li>Use simple short phrases </li></ul><ul><li>Ask specific rather than general questions </li></ul><ul><li>Distract if asking same question repeatedly </li></ul><ul><li>Assist in word finding </li></ul><ul><li>Reassure that you intend to help </li></ul><ul><li>Avoid arguing </li></ul><ul><li>Convey patience and understanding </li></ul>Promote Safety Communication
  20. 20. Tips for Dementia Care Cont. <ul><li>Establish regular & predictable routine </li></ul><ul><li>Breakdown complex tasks into small simple steps </li></ul><ul><li>Consistent care by regular staff </li></ul><ul><li>Use large clock & calendar </li></ul><ul><li> distraction & stimulation, avoid clutter & unnecessary objects </li></ul><ul><li>Post lists of daily activities </li></ul><ul><li>Person wear glasses & hearing aid </li></ul><ul><li>Avoid medications if possible </li></ul><ul><li>Check person frequently </li></ul>Decrease Confusion
  21. 21. Tips for Dementia Care Cont. <ul><li>Encourage regular exercise </li></ul><ul><li>Ensure nutrition & hydration </li></ul><ul><li>Assist with ADLs </li></ul><ul><li>Assess frequently for physical pain, constipation, & discomfort </li></ul><ul><li>Evaluate agitation and worsening behavior carefully </li></ul><ul><li>Suggest day treatment for clients living at home </li></ul><ul><li>Teach ways to manage uncooperative behavior </li></ul><ul><li>Teach about causes and course of dementia </li></ul><ul><li>Monitor & assess level of stress on the family </li></ul><ul><li>Encourage use of social support to decrease caregiver stress </li></ul><ul><li>Help families mourn the loss of their loved one </li></ul>Physical & Emotional Wellbeing Family Education Schober, Glod, Jones, 1998, p. 251
  22. 22. Modern ECT <ul><li>Causes changes in monoamine neurotransmitter system </li></ul><ul><li>Electric current (70 - 150 volts) passes through the brain from .5 to 2 seconds </li></ul><ul><li>Seizure must last approximately 30 - 60 seconds for therapeutic value </li></ul><ul><li>ECT has cumulative effect, needing 220 - 250 seconds </li></ul><ul><li>Oximeter-monitor anesthetic to assure oxygenation </li></ul><ul><li>2 - 3 times/week up to 6 - 12 treatments </li></ul><ul><li>May require periodic or maintenance ECT treatments </li></ul>
  23. 23. Disorders, Depressive Symptoms, & Conditions Responding to ECT
  24. 24. Preparation for ECT <ul><li>Physical exam, blood ct., chemistry, urinalysis, & baseline memory abilities </li></ul><ul><li>Consent form “informed” </li></ul><ul><li>Eliminate benzodiazepines prior </li></ul><ul><li>Trained electrotherapist & anesthesiologist </li></ul><ul><li>Nursing responsibilities </li></ul><ul><ul><li>NPO 8 hours prior to ECT </li></ul></ul><ul><ul><li>Atropine 1 hr. prior to treatment </li></ul></ul><ul><ul><li>Have patient urinate before treatment </li></ul></ul><ul><ul><li>Remove hairpins & dentures </li></ul></ul><ul><ul><li>Take vital signs </li></ul></ul><ul><ul><li>Reduce anxiety--be positive </li></ul></ul>
  25. 25. Procedures During ECT <ul><li>IV inserted </li></ul><ul><li>Electrodes placed on head </li></ul><ul><li>Bite-block inserted </li></ul><ul><li>Brevital IV </li></ul><ul><li>Anective IV, neuromuscular blocking agent </li></ul><ul><li>Ventilate 100% O 2 </li></ul><ul><li>Electrical impulse 150 volts, 0.5 - 2 sec. </li></ul><ul><li>Monitor, heart rate, rhythm,BP, EEG </li></ul>
  26. 26. Nursing Care After ECT <ul><li>Ventilate with 100% O 2 until breathing unassisted </li></ul><ul><li>Monitor for respiratory problems </li></ul><ul><li>Reorient patient, time, place, person </li></ul><ul><li>If agitation may need benzodiazepine </li></ul><ul><li>Constant observation </li></ul><ul><li>Document all aspects of treatment </li></ul><ul><li>Monitor seizure activity, EEG </li></ul>
  27. 27. Contraindications for ECT <ul><li>Very High Risk </li></ul><ul><ul><li>Recent myocardial infarction </li></ul></ul><ul><ul><li>Recent CVA </li></ul></ul><ul><ul><li>Intracranial mass lesion </li></ul></ul><ul><li>No absolutes </li></ul><ul><li>High Risk </li></ul><ul><ul><li>Angina pectoris </li></ul></ul><ul><ul><li>Congestive heart failure </li></ul></ul><ul><ul><li>Extremely loose teeth </li></ul></ul><ul><ul><li>Severe pulmonary disease </li></ul></ul><ul><ul><li>Severe osteoporosis </li></ul></ul><ul><ul><li>Major bone fractures </li></ul></ul><ul><ul><li>Glaucoma </li></ul></ul><ul><ul><li>Retinal detachment </li></ul></ul><ul><ul><li>Thrombophlebitis </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><ul><li>Use of MAOIs </li></ul></ul><ul><ul><li>Use of clozapine </li></ul></ul>
  28. 28. Disadvantages ECT <ul><li>Temporary relief </li></ul><ul><li>Memory impairment, before and after ECT </li></ul><ul><li>Physiological effects </li></ul><ul><ul><li>hypertension </li></ul></ul><ul><ul><li>arrhythmias </li></ul></ul><ul><ul><li>alterations in cardiac output </li></ul></ul><ul><ul><li>hemodynamic changes </li></ul></ul><ul><ul><li>increases in myocardial o 2 consumption-ischemia </li></ul></ul><ul><ul><li>seizures </li></ul></ul>
  29. 29. Other Somatic Therapies <ul><li>Psychosurgery </li></ul><ul><li>Insulin-Coma </li></ul><ul><li>Metrazol-induced convulsions </li></ul>
  30. 30. Psychosurgery <ul><li>Types </li></ul><ul><ul><li>Cingulotomy </li></ul></ul><ul><ul><li>Subcaudate tractotomy </li></ul></ul><ul><ul><li>Capsulotomy </li></ul></ul><ul><li>Outcomes, psychosurgeries </li></ul><ul><ul><li>Suicide rate of 1300 persons dropped 15% to 1% post op </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li><20 yrs or >65 yrs </li></ul></ul><ul><ul><li>brain pathology, atrophy or tumor </li></ul></ul><ul><ul><li>personality disorders: borderline, paranoid, antisocial, histrionic </li></ul></ul><ul><ul><li>substance abuse </li></ul></ul><ul><li>Adverse Reactions </li></ul><ul><ul><li>Altered personality </li></ul></ul><ul><ul><li>infection, hemorrhage, hemiplegia,seizures, suicide, wt. gain </li></ul></ul>
  31. 31. Phototherapy: Seasonal Affective Disorder <ul><li>Light box </li></ul><ul><li>Phototherapy visor </li></ul><ul><li>Head-mounted light unit </li></ul><ul><li>Dawn stimulator </li></ul>

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