Transcript Cognitive Disorders, Behavior Therapy, ECT

Cognitive Disorders
ECT
Phyllis M. Connolly, PhD, RN, CS
NURS 127A
Questions for consideration
• What are the similarities and differences
between delirium, dementia, and
depression?
• What is a catastropic reaction and what
interventions are helpful?
• What is a positive client outcome for altered
thought processes?
• What the indications for ECT?
Cognitive Impairments
• 2.4 million Americans suffer from dementing
illnesses
• 7.3 million by 2040
• Alzheimer’s Disease
• Dementias
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Vascular--interruption of blood flow to brain
Parkinson’s--involves extrapyramidal
Diffuse Lewy Body Disease
Huntington’s Disease
• Creutzfeldt-Jakob Disease
• Alcoholic Dementia
• TIA
Medications Causing or Contributing
to Dementia or Delirium
• Analgesics
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Codeine
Meperidine
Morphine
Pentzcocine
Indomethacin
• Antihistamines
– Dephenhydramine
– Hydroxyzine
• Antihypertensives
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Clonidine
Hydralazine
Methyldopa
Propranolol
Reserpine
• Antimicrobials
– Gentamicin
– Isoniazid
Medications Causing or Contributing to
Dementia or Delirium Cont.
• Antiparkinsonism
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Amantadine
Bromocriptine
Carbidopa
L-Dopa
• Cardiovascular
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Atorpine
Digitalis
Diuretics
Lidocaine
• Hypoglycemics
– Insulin
– Sulfonyureas
• Psychotropics
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Benzodiazepines
Lithium
Tricyclics
Haloperidol
Thiothixene
Chlorpromazine
Barbituates
– Chloral hydrate
• Others
– Cimetidine
– Steroids
– Trihexyphenidyl & other
anticholinergics
Dementia
• Constellation of symptoms resulting in
impairment of short and long term memory
• Onset slow or insidious
• Progressive ends in death
• Deterioration in judgment & abstract
reasoning
• Social & occupational functioning
significantly affected
• Most common cause Alzheimer’s
Four As of Alzheimer’s Disease
• Amnesia--inability to learn new information
or to recall previously learned information
• Agnosia--failure to recognize or identify
objects despite intact sensory function
• Aphasia--language disturbance that
manifest in both understanding &
expressing the spoken word
• Apraxia--inability to carry out motor
activities despite intact motor function
Alzheimer’s: Etiology
• Senile plaques & neurofibrillary tangles
• Dystrophic neurites(thickened, swollen
neuronal processes)
• Abnormal amyloid deposits
• Genetic--10-15% of cases
• Toxin model--aluminum salts
• Infectious agent model--virus
• Cholinergic deficit model
Alzheimer’s Disease: Behavioral
Symptoms
• Hallucinations
• Delusions
• Dysphoria &
depression
• Fearfulness
• Repetitive
purposeless acts
• Avoidance behavior
• Motor restlessness
• Apathy
• Verbal and physical
aggression
• Resistance to
interventions
– Hygiene
– Nutrition
– Safety
Stressors for Persons with Cognitive
Impairments
• Fatigue
• Change of environment, routine or
caregiver
• Overwhelming or competing stimuli
• Demands that exceed capacity to function
• Physical stressors
Catastropic Reaction
• Excessive distress exhibited by patients in
situations that are confusing or frightening
ex. Showering
• Interventions
– Remain calm
– Remove patient from whatever is upsetting
– Use distraction rather than confrontation
Impaired Cognitive Functioning
• Key Elements of Care
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Communication
Orientation
Structure
Stimulation
Safety
Altered Thought Processes
• Client Outcomes
– Demonstrates improved reality orientation
– Responds coherently to simple requests
– Follows simple directions
• Interventions
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Baseline mental status & functioning
Avoid making demands
Ask only one question & make only one request at a time
Provide a structured routine
Provide familiar objects
Avoid agreeing with confused thinking but DO NOT ARGUE--try to
distract
– Incorporate orientation cues from the environment
– Keep environment simple & uncluttered
Delirium
• Alterations in consciousness
• Changes in cognition
• Usually caused by medical condition or substance
induced
• Develop over short period of time
• Treatable
• 30% CCU environments, “CCU psychosis”
• Disoriented
• Disorganized thinking and speech
• Altered perceptions: illusions, delusions & hallucinations
• EEG changes
• Neurological abnormalities
Delirium: Treatment
• Identify & correct cause
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anemia
dehydration
nutritional deficiencies
electrolyte imbalance
Monitor closely
Safety high priority
Control behavioral symptoms
Well lighted room, visible clock & calendar
Comparison Dementia, Delirium
& Depression
Dementia
Delirium
Depression
Cause may be
unknown
Can become
chronic
Insidious
Cause may be
identified
Time limited
Cause may be
identified
Time limited
Acute onset
Insidious
Not often treatable Always treatable
or reversible
Consciousness,
Clouded
normal
Usually treatable
Normal
Psychotherapeutic Management
• Nurse-Patient Relationship
• Psychopharmacology
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Antipsychotics
Antidepressants
Antianxiety
Treatment of cognitive impairment
• cholinergic enhancers
• metabolic enhancers/vasodilators
• Nootropic agents
– Milieu management
• Safety
Validation Therapy
• Enter client’s world rather than force to
relate to an external world which is no
longer comprehensible
• Increase the client’s sense of being
understood by others
• Reduces agitation and catastrophic
reaction
• quality of life
Schober, Glod, Jones,
1998, p .252
Tips for Working with Persons with
Dementia
Promote Safety
• Person wears identification
bracelet
• Install special locks, safety
devices on doors, stove &
other potentially
dangerous objects
• Check frequently for burns,
bruises, or abrasions
• Assess for signs of abuse
• Only use restraints after
other methods are
ineffective--need MD order
Communication
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Look directly at person when
speaking
• Identify yourself prior to
interaction
• Use simple short phrases
• Ask specific rather than general
questions
• Distract if asking same question
repeatedly
• Assist in word finding
• Reassure that you intend to help
• Avoid arguing
• Convey patience and
understanding
Tips for Dementia Care Cont.
Decrease Confusion
• Establish regular & predictable
routine
• Breakdown complex tasks into
small simple steps
• Consistent care by regular staff
• Use large clock & calendar
•  distraction & stimulation,
avoid clutter & unnecessary
objects
• Post lists of daily activities
• Person wear glasses & hearing
aid
• Avoid medications if possible
• Check person frequently
Tips for Dementia Care Cont.
Physical & Emotional
Wellbeing
• Encourage regular
exercise
• Ensure nutrition &
hydration
• Assist with ADLs
• Assess frequently for
physical pain,
constipation, & discomfort
• Evaluate agitation and
worsening behavior
carefully
• Suggest day treatment for
clients living at home
Family Education
• Teach ways to manage
uncooperative behavior
• Teach about causes and
course of dementia
• Monitor & assess level of
stress on the family
• Encourage use of social
support to decrease
caregiver stress
• Help families mourn the
loss of their loved one
Schober, Glod, Jones,
1998, p. 251
Modern ECT
• Causes changes in monoamine neurotransmitter
system
• Electric current (70 - 150 volts) passes through
the brain from .5 to 2 seconds
• Seizure must last approximately 30 - 60 seconds
for therapeutic value
• ECT has cumulative effect, needing 220 - 250
seconds
• Oximeter-monitor anesthetic to assure
oxygenation
• 2 - 3 times/week up to 6 - 12 treatments
• May require periodic or maintenance ECT treatments
Disorders, Depressive Symptoms, &
Conditions Responding to ECT
DISORDERS
DEPRESSIVE
SYMPTOMS
Severe depression Anhedonia
85 – 90%
CONDITIONS
Tardive dystonia
Treatmentrefractory
depression
Catatonia
Anorexia
Tardive dyskinesia
Delusions
Akathisia
Mania
Insomnia
Some types of
schizophrenia
Muteness
Parkinsonian
symptoms
Neuroleptic
malignant
syndrome
Psychomotor
retardation
Suicidal ideation
Preparation for ECT
• Physical exam, blood ct., chemistry, urinalysis, &
baseline memory abilities
• Consent form “informed”
• Eliminate benzodiazepines prior
• Trained electrotherapist & anesthesiologist
• Nursing responsibilities
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NPO 8 hours prior to ECT
Atropine 1 hr. prior to treatment
Have patient urinate before treatment
Remove hairpins & dentures
Take vital signs
Reduce anxiety--be positive
Procedures During ECT
• IV inserted
• Electrodes placed on
head
• Bite-block inserted
• Brevital IV
• Anective IV,
neuromuscular blocking
agent
• Ventilate 100% O2
• Electrical impulse 150
volts, 0.5 - 2 sec.
• Monitor, heart rate,
rhythm,BP, EEG
Nursing Care After ECT
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Ventilate with 100% O2 until breathing unassisted
Monitor for respiratory problems
Reorient patient, time, place, person
If agitation may need benzodiazepine
Constant observation
Document all aspects of treatment
Monitor seizure activity, EEG
Contraindications for ECT
• Very High Risk
– Recent myocardial
infarction
– Recent CVA
– Intracranial mass
lesion
No absolutes
• High Risk
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Angina pectoris
Congestive heart failure
Extremely loose teeth
Severe pulmonary disease
Severe osteoporosis
Major bone fractures
Glaucoma
Retinal detachment
Thrombophlebitis
Pregnancy
Use of MAOIs
Use of clozapine
Disadvantages ECT
• Temporary relief
• Memory impairment,
before and after ECT
• Physiological effects
– hypertension
– arrhythmias
– alterations in cardiac
output
– hemodynamic changes
– increases in myocardial
o2 consumptionischemia
– seizures
Other Somatic Therapies
• Psychosurgery
• Insulin-Coma
• Metrazol-induced convulsions
Psychosurgery
• Types
– Cingulotomy
– Subcaudate tractotomy
– Capsulotomy
• Outcomes, psychosurgeries
– Suicide rate of 1300 persons dropped 15% to 1% post op
• Contraindications
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<20 yrs or >65 yrs
brain pathology, atrophy or tumor
personality disorders: borderline, paranoid, antisocial, histrionic
substance abuse
• Adverse Reactions
– Altered personality
– infection, hemorrhage, hemiplegia,seizures, suicide, wt. gain
Phototherapy:
Seasonal Affective Disorder
• Light box
• Phototherapy visor
• Head-mounted light
unit
• Dawn stimulator