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78 Cards in this Set
- Front
- Back
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Cognition
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the use of intellect, judgement, and reason which involves obtaining, storing and retrieving information and knowledge in a purposeful manner.
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Judgement
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the ability to perceive and distinguish alternatives with the capacity for making reasonable decisions
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memory
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storing and retrieving of information
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Cerebral cortex cognition process
Parietal & occipital - Temporal - Frontal - |
P & O - attends to stimuli
Temp - identifies stimuli Frontal - plans appropriate response |
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Semantic memory
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learning the concepts creates more pathways to get there (good for studying)
inc pathways -> inc in storage power repeated reliving enhances permanence. |
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What are some SYSTEMIC disturbances that can be the etiology of a cognitive disorder?
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- Exogenous substances (includ prescribed meds)
- Infection of CNS or any systemic infection - Fluid & electrolyte disturbances. - Organ failure - Vitamin def. - VERY BROAD ETIOLOGY |
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What are some NEUROLOGIC disturbances that can be the etiology of a cognitive disorder?
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Neurologic disorders
Brain injuries: -ischemia -lesions -trauma |
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What are some general responses to cognitive impairment?
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impaired judgement
impaired orientation memory loss lability of affect |
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Dementia patient loses memory in what order r/t short or long term memory?
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short term first.
patient loses memory in reverse order (present to long term) - Time, place, what they had for breakfast – but will remember Labor Day 1987 |
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In what stage is lability seen in dementia?
When lability goes away, what often comes next? |
may be depressed b/c they know they are having difficulty in early stages. Depression goes away and anxiety will develop b/c they are losing their environment and feel afraid.
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Of the 3 D's who is at greatest risk for injury?
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Delirium patients
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Delirium:
What is the key symptom to distinguish from the other D's? Onset is: |
acute confusion
Key symptom: fluctuation in LOC onset is rapid |
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T or F
Delirium is a disease |
FALSE
Delirium is a SYNDROME |
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Neuropathophysiology of Delirium
r/t to a ____ |
r/t decrease in ACh activity
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A decrease in ACh activity will have what effect?
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affects reticular formation, which regulates attn and arousal -> disruption in sleep/wake cycle.
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Frequent causes of delirium
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Intracranial: epilepsy & postictal states, brain trauma (esp concussions), infections (meningitis), neoplasms, vascular DO
Extracranial: systemic disturbances, exogenous substances Risks: age - older and the younger sensory problems, environment - moving a patient to a different floor – different environ, diff stimulation – can last 1-2 days. |
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What is the most common cause of delirium?
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systemic infection
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What are the early indicators of impending delirium?
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uneasiness
irritability malaise daytime somnolence (some may have fine tremors) |
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What is the most common cause of systemic infection in older adults?
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UTI
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Clinical features of delirium
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- changes in wakefulness
- Cognition - Altered sensory perceptions – see something there, but misinterpret it. (see the phone on wall as a squirrel) -In there environ you don’t want bright lights, but you want to eliminate shadows. -Eliminate mirrors – seeing themselves in mirror can cause confusion. -sun downing - Affect - anxious, agitated, frightened – b/c of short term memory problems - Psychomotor - wide fluctuations, unpredictable – may be talking to you one second and swinging at you the next -Autonomic arousal – flight or fight response seen. |
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Dementia
Is it reversible? Onset is? most common type? |
memory and cognitive impairment WITHOUT impairment in consciousness
Can be reversible or progress to permanent (secondary vs primary) onset is gradual dementia alzheimer's type (DAT) 70%; 2nd is Vascular older you get the higher the risk; can have early onset (<45yo); earlier the onset the faster the progression |
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When can you be diagnosed with DAT?
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after death determined by autopsy
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Diagnostic criteria for DAT must have development of multiple cognitive deficits manifested by?
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memory impairment AND
1 or more cognitive disturbances -aphasia: speech disturbance – use words incorrectly or cant find the words -apraxia: problems w/ movement, trouble w/ ADLs, can remember how to walk -agnosia: sensory problems, diff recognizing familiar things. -disturbance in executive functioning- loss of ability to organize thinking. |
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4 Functional changes in Alzheimer's
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LANGUAGE: confabulation (person makes things up), perseveration (stuck on topic cant get off it), aphasia
PERCEPTUAL/ SENSORY: delusions, hallucinations, agnosia EMOTIONS BEHAVIOR: poor hygiene, hoarding, impulsivity, roaming, pacing and wandering, apraxia |
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What are the most common type of delusions in DAT?
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paranoid
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Etiology of DAT: Neurochemistry
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- dec ACh
- inc glutamate - low levels all the time messes up Ca channels and there are low levels of Ca in the cell, which can kill the cell. Others affected: NE, 5HT, Dopamine - Only will target other neurotrans w/ medication if there are symptoms that are distressing to that person. Main focus in on ACh. |
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Etiology of DAT
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Multiple genes
Chromosome #19: Apolipoprotein E (apoE) apoE4 - inc risk apoE2 - dec risk Chromosome: CYP46 - has to do w/ cholesterol, helps brain to metabolize cholesterol. Beta-amyloid – functions to maintain nerve tissue in the brain. Inc cholesterol in brain. Estrogen patients have inc risk. |
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Etiology of structural changes in DAT
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Brain atrophy
Enlarged cerebral ventricles Microscopic changes |
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What 3 microscopic changes occur in DAT?
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amyloid accumulation
granulovascular degeneration neurofibrillary tangles and plaques |
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Plaques result from?
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APP (amyloid precursor protein) -> Beta amyloid fragments -> Plaques
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Tangles occur b/c of?
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TAU protein normallaly stabilizes neurons and activity btwn neuron - but in alz. little ridges twist.
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4 Stages of ADT
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1) Forgetfullness - depression common
2) Confusion Can’t really live alone at this point. Need monitoring to make sure they are safe. Driving no longer possible. 3) Ambulatory Dementia Has ability to walk, but communication skills have declined. Needs round the clock care. Easily overwhelmed. 4) End Stage Loss of recognition. Forgets how to eat/ toilet. Progresses to stupor/ coma. |
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Vascular Dementia:
Hx of what 2 things can lead to VD? Onset is? Cognitive functiong/ loss is? |
Multiple brain infarts result in death of neurons.
- Hx of hypertension and/or cerebrovascular disease - onset is more acute then other dementias - loss is "patchy" - Focal neurological signs- gait problems, limb they cant move, emotional dis-control – episodes where they will start to cry and cant stop. |
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Other categories of Dementia due to
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Head truma
Pick's dx - affects frontal lobe Huntington's dx - genetic motor mvmt dx, symptoms do not show up until late 30’s – 40’s, very high suicide rate. Common to see in families. Creutzfeldt-Jakob dx HIV dx (less then 1% of dementia) Substance induced persisting - not reversible other general medical conditions multiple etiologies (also Parkinsons Dx) |
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Review of possible etiologies for dementia
D E M E N T I A |
D: Drug rxns, overdoses, and ETOHism
E: emotional disorders M: metabolic & endocrine disorders E: eyes and ears N: nutritional deficiences T: tumors I: infection A: atherosclerosis & CHE |
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FYI
comorbidity with dimentia 40-50% have ____ & ____ 10-20% have _______ 10% of patients w/ DAT and 20% of patients w/ vasucular dementia have? |
depression & anxiety
major depressive disorders seizures |
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Pseudodementia
clinical features |
cognitive and memory impairments which are symptoms of depression
treatable and reversible Clinical features - cognitive impairment - memory impairment - associated features - supplemental - course and progression is treatable and reversible |
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What percent of people thought to have dementia actually have a depressive disorder?
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15%
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What should be included in the focused health history for a patient w/ possible dementia?
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family hx
mood affective changes cognitive changes behaviroal changes physical changes functional changes environment assesment |
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Emphsis of Physical Assessment should include what 2 aspects?
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1) signs of damage to the nervous system.
2) evidences of diseases of other organs that could affect mental function. |
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Who should be screened for depression?
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EVERY older adults
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Screening/ Assessment scales
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Mental Status Examination for Dementia
Functional/ ADL assessment scales Geriatric Depression/ Mood Scales Hachinski Index **scales need to be specific to older persons to determine if there is depression. |
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Family Assessment for patients with dementia should be done to assess for what?
It should include what? |
families ability to care for the individual – and that they are healthy enough to do it.
Relationship Health Stress Impact Support Finances |
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What are the priority nursing diagnosis for DELIRIUM?
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risk for injury
anxiety acute confusion |
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What are the priority nursing diagnosis for DEMENTIA?
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risk for injury
altered thought process chronic confusion |
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What are the priority nursing diagnosis for FAMILY/ CAREGIVER of a patient with dementia?
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caregiver role strain
ineffective family coping fatigue |
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Other important nsg diagnosis for dementia and delirium
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self care deficit
altered nutrition altered elimination |
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What is the therapeutic management for delirium?
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- assess and treat the underlying cause
- promote oxygen exchange - supportive care - minimize sensory impairment - modify the environment - streamline medications - Pharmacological treatments (1st line: Haldol; 2nd: short acting Benzo - Adavan) - Safety measures |
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What is the 1st and 2nd line treatment for delirium?
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1st: Haldol
2nd: short acting Benzo - Adavan |
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What medications do you need to watch for in treating the D's?
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- Anticholinergic activity (TCA's, atropine, OTC antihistamines, eye gtt, etc)
- H2 blockers - Analgesics (Demerol, NSAIDS) - Sedative/ hypnotics - Cardiac drugs |
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Why do you not want to give anticholinergics when treating the D's?
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We need to have the cholinergic receptor sites open.
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Therapeutic management of environment what can nurses do?
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- clear, simple communication
- continuity of caregivers, location - eliminate unnecessary stimuli (turn off TV, remove equipment not being used) - orienting stimuli (things familiar to patient) - orienting possessions |
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How should you communicate to confused patients?
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- face to face - so they know where the voice is coming from.
- space and body language - non threatening. Space for your safety. - clear, simple - slow - focus on one topic - acknowledge feelings - reinforce reality OR distract and shift focus |
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In delirium and depression where should the focus of communication be?
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on reality
Dementia – focus on their reality! (one time this is okay) – you can also try to distract like if they think there is a fire and there is no fire. |
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Psychosocial interventions for Dementia
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- individual and group therapies
- self care activities - family interventions |
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Dimentia Milieu
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Routines and schedules
Orienting objects Symbols, colors, & signs Label clothing & objects Decrease noise Diversion activities Lighting and potential objects Space for wandering. |
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Why are stop signs a good way to keep dimentia patients from wandering into areas they should not go?
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Stop signs are a part of long term memory - they remember to stop.
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What considerations should be taken into consideration when prescribing psychotropic meds to the elderly?
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- combined w/ diuretics - hypotension, confusion
- Hypnotics - may dec body temp - Psychoactive meds - may dec visual accommodation - more vulnerable to toxicity (liver and renal function changes) - experience more paradoxical rxns |
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General Pharm NI's for cognitive disorders
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- antipsychotics - low dose, usually Haldol (or oral resparidol)
- anti-anxiety - short acting Benzo so in case they become sedated it wont last long. - antidepressants - mood stabalizers - maybe Lithium or Depicoat. |
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Use of cholinesterase inhibitors in DAT
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- slows proression, only 30% benefit from this treatment, many cannot tolerate the SE.
Once in the severe stage this is not usually prescribed. Once there is no receptor sites it does not benefit them. Adverse effects: N/V/D, anorexia, dizziness, HA Interactions: traditional antipsychotics, TCAs, antihistamines |
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N-Methyl-D Aspartic (NMDA) receptor antagonists
- used alone or in combination w/____ - Action inhibits _____ |
cholinesterase inhibitors
inhibits glutamate Adverse effects: dizziness, HA, confusion, constipation |
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Pharm treatments for dementia continuing to be researched
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NSAIDS
Vit E (and others) Ginkgo Biloba Amyloid vaccine Estrogen |
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According to the latest research how does estrogen effect dementia?
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increases the risk of dementia
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Onset of
Delirium Dementia Pseudodementia |
Delirium - Acute/subacute, depends on cause; often at twilight or in darkness
Dementia - Chronic, insidious, depends on cause Pseudodementia - Coincides with major life changes, often abrupt |
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Course of
Delirium Dementia Pseudodementia |
Delirium - Short, diurnal fluctuations of symptoms, worse at night and awakening
Dementia - Long, no diurnal effects, symptoms progressive yet stable over time Pseudodementia - Diurnal effects, typically worse in the morning |
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Progression of
Delirium Dementia Pseudodementia |
Delirium - abrupt
Dementia - Slow but uneven Pseudodementia - Variable but even |
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Duration of
Delirium Dementia Pseudodementia |
Delirium - Hours to less than one month, seldom any longer
Dementia - Months to years Pseudodementia - At least 2 weeks, can be months to years |
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Awareness of
Delirium Dementia Pseudodementia |
Delirium - reduced
Dementia - clear Pseudodementia - clear |
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Alertness of
Delirium Dementia Pseudodementia |
Delirium - Fluctuates, lethargic or hypervigilant
Dementia - generally normal Pseudodementia - normal |
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Attention:
Delirium Dementia Pseudodementia |
Delirium - Impaired, fluctuates
Dementia - generally normal Pseudodementia - minimal |
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Orientation:
Delirium Dementia Pseudodementia |
Delirium - Generally impaired, severity varies
Dementia - may be impaired Pseudodementia - "patchy" |
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Memory:
Delirium Dementia Pseudodementia |
Delirium - Recent and immediate impaired
Dementia - Recent and remote impaired Pseudodementia - "patchy" |
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Thinking:
Delirium Dementia Pseudodementia |
Delirium - Disorganized, distorted, fragmented; incoherent speech (slow / accelerated)
Dementia - Difficulty with abstraction, impoverished thoughts, impaired judgement Pseudodementia - Intact but with themes of hopelessness, helplessness, or self-deprecation |
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Perception:
Delirium Dementia Pseudodementia |
Delirium - Distorted, illusions, delusions and hallucinations, misperceptions of reality
Dementia - Misperceptions usually absent Pseudodementia - Intact, delusions and hallucinations absent except in severe cases |
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Psychomotor behavior:
Delirium Dementia Pseudodementia |
Delirium - Variable
Dementia - Normal, may have apraxia Pseudodementia - Variable (agitation or retardation) |
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Sleep/ wake cycle:
Delirium Dementia Pseudodementia |
Delirium - Disturbed, cycle reversed
Dementia - Fragmented Pseudodementia - Disturbed, usually early awakening |
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Associated features:
Delirium Dementia Pseudodementia |
Delirium - Variable affective changes, associated with acute physical illness
Dementia - Affect: superficial, inappropriate & labile; attempts to conceal deficits Pseudodementia - Affect depressed, dysphoric mood, exaggerated and detailed complaints |
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Mental Staus testing:
Delirium Dementia Pseudodementia |
Delirium - Distracted from task, numerous errors
Dementia - Struggles with test, frequent "near miss" answers Pseudodementia - Frequent "don’t know" responses, indifferent, gives up |
