Transcript Cognitive Disorders

Cognitive Disorders
Elisa A. Mancuso RNC, MS, FNS
Professor
Delirium
 Identified cerebral disease or dysfunction
– Acute & fluctuating
 Impaired cognition
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Decision making
Problem solving
Interpreting environment
Learning new information
 Disturbed consciousness
– Disoriented to time & place
– Illusions, hallucinations, anxiety, & ▲ sleep
patterns
 Psychomotor Agitation
Delirium Etiology
 General Medical Conditions
 UTI URI
CHF (Older acutely ill)
 Systemic Disturbances
PN
 Fluid/Electrolyte imbalance
 Thiamine deficiency
 Exogenous Substances
 Heavy metals- Lead (Pb)
 ↑↑ Coke
Heroin
 Medications
 Benzodiazepenes
 Analgesics
 Neuroleptics
Mercury (Hg)
Marijuana
ETOH
Sedatives/Hypnotics
Anticonvulsants
Diuretics
Antihypertensives
Digoxin
Resolve underlying cause & condition improves!
Dementia
Develops slowly
80% Irreversible
Progressive deterioration
 Multiple Cognitive Deficits
Impaired short & long term memory
Aphasia: ↓Language
Apraxia: ↓ Motor function
Agnosia: Inability to recognize objects
↓ Abstract Thinking
Senile Dementia
6% people > age 65
or
30% > age 90
Syndrome of acquired, persistent intellectual impairment
Etiology
 Cerebral hypoxia
Intracranial tumors
 Hydrocephalus
MS
 Hypertensive Encephalopathy
Symptoms
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Short-term memory deficit
Aphasia
Confabulation
Blocking
↓ Abstract thinking
Poor judgment & impulse control
Disintegrating personality
Alzheimer’s Degenerative Dementia
70% of all dementia = 4 million people
Slow & insidious onset
Progressive & chronic deterioration
– 8-15 years from onset
 Women 2x>men
 Irreversible
 ACh deficiency =↓ neuron impulse
 ↑ Aluminum accumulation
 Altered immune system
– ↑ Ab titers (Protein A-68)
 ↑ Beta Amyloid
– Neuronal plaques Neurofibrillary tangles
– Cortex atrophy
Alzheimer’s
Predisposing Factors
 Head trauma
 Genetic: Chromosome # 14, 19 & 21
 Vascular injury 2 to HTN or cerebral emboli
 Huntington’s Chorea
 Parkinsons Disease
 Pick’s Disease
– Degeneration of frontal lobe
 Creutzfeldt-Jakob Disease
– Infectious process
 Secondary to HIV
Alzheimer’s Phases
 Phase I : Forgetfulness (1 year)
– Short term memory loss (Absent minded)
– Lose things & forget names of people
– Pt aware & tries to compensate
– Anxious & fearful regarding losing abilities
– Frustrated
Alzheimer’s Phases
 Phase II : Confusion (2-12 years)
– Hyperorality
– Tantrums & Wandering
– Sundowning
 Afternoon Worsening: Agitation & Confusion
– Difficulty concentrating yet denies problem
 Lost when driving
 ↓ Work performance
 Inability to learn new information or recall information
– Perservation
 Verbalize same idea repeatedly
– Agnosia
 Failure to identify objects
Alzheimer’s Phases
 Phase III- Terminal Dementia (8 mos -2
years)
– Severe & significant decline in functioning
– ↓ Memory of major life events & family members
– Regression
– Poor impulse control
 ↑ Sexual behavior
– Unable to do ADLs independently
 Incontinent
– Delusions, Hallucinations, Anxiety
– Aphasia, Agraphia & Apraxia
– Final vegetative state
Nursing Interventions
Physical Exam
– R/O any organic cause
 PET, CT, MRI
 √ Neurofibrillary tangles & atrophy of cortex
Hx of onset
 Family, friends & colleagues
Assess Mental Status
Orientation
Concentration
Coordination
Judgment
Affect
Memory
Abstract Thinking
Sensory Perception
Nursing Interventions
 PALMER
– Perception
– Attention Span
– Language
– Memory
– Emotional Control
– Reasoning & Judgment
Nursing Interventions
# 1 Patient Safety!
– ID bracelet
– Notify Police & local stores
– Recent photo & all contact #s
– Physical Environment
 Security system in home
 Childproof
 Consistent & uncluttered
 ↓ Stimulation
 Well lit & handrails
Nursing Interventions
 Psychological Support
– Supportive touch
– Promote interaction
 Group activity
– Reminiscence therapy
 Life review
 Stimulates remote memory
 Promotes ↑self-esteem
– Distraction
 Music therapy
Nursing Interventions
 ADLs
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Allow Pt to make simple choices = ↑ control
Break down tasks to short, simple steps = KISS
Give verbal & visual cues
Clear expectations
Allow ample time to perform
 Velcro, elastic, large zippers & sneakers
 Exercise
– ROM PT & daily walks
– ↑ activity in day ↓ wandering @ night
Nursing Interventions
 Nutrition
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Keep mealtimes consistent
Provide finger foods
Balance diet with↑ calorie liguids
Weigh weekly
Use bowls & spoons
Bibs & drop cloths
 Elimination
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√I&O
↓ Fluids @ bedtime
Toilet @ regular intervals q 2h
Incontinent products
Medications
Help delay or prevent worsening of symptoms
Start low & go slow with dosages!
Cholinesterase Inhibitors
 Donepezil (Aricept)
– Slows the natural breakdown of ACh = ↑ ACh
– Only effective on intact cholinergic neurons
– SE
 Insomnia = ↑ Wandering
 Diarrhea N & V
 Rivastigimine (Exelon)
– Transdermal Patch
– SE
N&V
Abdominal pain
↓Appetite
Cholinesterase Inhibitors
 Galantamine (Reminyl, Razadyne)
– SE
N & V
↓Appetite
Dizziness
 Memantine (Nemenda)
– ↑ Availabilty of ACh
– Target symptoms @ mod → severe stage
– Time limited benefits
– SE
 ↑↑ BP
Pain
HA
 Vomiting
Constipation
Symptomatic Management
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Anxiolytics
 Short term use to ↓ anxiety
 BuSpar best = ↓ cognitive & psychomotor SEs
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Antipsychotics
 ↓ Agitation
↓ Aggression
↓ Hallucinations
 ↓ Paranoid thinking
 Zyprexia & Seroquel best = ↓ EPS
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Antidepressants
 ↑ Sleeping ↑ Thinking ↑ Memory ↑ Appetite
 TCA ¼ -1/2 dose
– Bupropion (Wellbutrin)
Vanlafaxine (Effexor)
 SSRIs
– No Fluoxetine (Prozac) inhibits liver enzymes &
 ↑ serum levels of other meds
– Paroxetine (Paxil)
Citalopram (Celexa)
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Anticonvulsants
 ↓ Impulsivity & aggression
 Valproic Acid (Depakote) & Carbamazapine (Tegretol)
Multidisciplinary Approach
 Speech Therapist
– Restore swallowing
– Delay aphasia
 Physical Therapist
– “Use it or lose it”
– Retain strength & memory
– Improve large & fine motor skills
 Occupational Therapist
– Sensory & Brain stimulation
Multidisciplinary Approach
 Social Worker
– Individual & Group Therapy
– Family Support
 Sandwich generation
 ↑ Caretaking demands & multiple roles
 Coping with feelings of personal loss
 Anticipatory Grieving
 Assistance from all relevant agencies
 Alzheimer's Association
– Community Resources
 Respite care
 Day Care Centers
 Residential Facilities
 Specialized Alzheimer’s units