Transcript Organic Mental Disorders

Organic Mental
Disorders
Elisa A. Mancuso RNC, MS, FNS
Professor
OMD Delirium
 Identified cerebral disease or dysfunction
– Acute & fluctuating
 Altered neuronal pathways
 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
Delirium Etiology
– General Medical Conditions
 UTI URI
CHF (Older acutely ill)
– Systemic Disturbances
 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!
OMD Syndromes
 Amnesic Disorders:
Wernicke or Korsakoff
– Chronic ETOH ingestion
– ↓ Nutrition = Thiamine (B1) deficiency
– Symptoms
 Confusion
 Disorientation
 ↑ Distractibility
 Impaired short & long term memory
OMD Syndromes
 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
 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 & 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!
 Tacrine (Cognex)
– Reversible Cholinesterase Inhibitor
– Slows the natural breakdown of ACh = ↑
ACh
– Slows progression of memory loss
– SE
 Diarrhea Diaphoresis
↑ Urination &
Salivation
 Hepatotoxicity
Medications
 Donepezil (Aricept)
– Slows the natural breakdown of ACh = ↑ Ach
– Only effective on intact cholinergic neurons
– SE
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Insomnia = ↑ Wandering
HA
Seizures
Diarrhea
N&V
Atrial fibrillation
 Rivastigimine (Exelon)
 Galantamine (Reminyl)
Symptomatic Management
 Anxiolytics
 Short term use to ↓ anxiety ↓
 BuSpar best = ↓ cognitive & psychomotor SEs
 Antipsychotics
 ↓Agitation ↓ Aggression ↓ Hallucinations
 ↓ Paranoid thinking
 Zyprexia & Seroquel best = ↓ EPS
 Antidepressants
 ↑ Sleeping ↑ Thinking ↑ Memory ↑ Appetite
 TCA ¼ -1/2 dose
– Amitriptyline (Elavil) Trazodone (Desyrel) Bupropion
(Wellbutrin)
 SSRIs
– No Fluoxetine (Prozac) inhibits liver enzymes & ↑ serum
levels of other meds
– Paroxetine (Paxil)
Citalopram (Celexa)
 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