Organic Mental Disorders

1. Organic Mental Disorders Elisa A. Mancuso RNC, MS, FNS Professor

2. OMD Delirium Identified cerebral disease or dysfunction Acute & fluctuating Altered neuronal pathways Impaired cognition Decision making Problem solving Interpreting environment Learning new information Disturbed consciousness Disoriented to time & place Illusions, hallucinations, anxiety, & ▲ sleep patterns

3. Delirium Etiology General Medical Conditions UTI URI CHF (Older acutely ill) Systemic Disturbances Fluid/Electrolyte imbalance Thiamine deficiency Exogenous Substances Heavy metals- Lead (Pb) Mercury (Hg) ↑↑ Coke Heroin Marijuana ETOH Medications Benzodiazepenes Sedatives/Hypnotics Analgesics Anticonvulsants Diuretics Neuroleptics Antihypertensives Digoxin Resolve underlying cause & condition improves!

4. OMD Syndromes Amnesic Disorders: Wernicke or Korsakoff Chronic ETOH ingestion ↓ Nutrition = Thiamine (B1) deficiency Symptoms Confusion Disorientation ↑ Distractibility Impaired short & long term memory

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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 Affect Concentration Memory Coordination Abstract Thinking Judgment Sensory Perception

12. Nursing Interventions PALMER Perception Attention Span Language Memory Emotional Control Reasoning & Judgment

13. 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

14. Nursing Interventions Psychological Support Supportive touch Promote interaction Group activity Reminiscence therapy Life review Stimulates remote memory Promotes ↑self-esteem Distraction Music therapy

15. Nursing Interventions ADLs 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

16. Nursing Interventions Nutrition Keep mealtimes consistent Provide finger foods Balance diet with↑ calorie liguids Weigh weekly Use bowls & spoons Bibs & drop cloths Elimination √ I & O ↓ Fluids @ bedtime Toilet @ regular intervals q 2h Incontinent products

17. 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

18. Medications Donepezil (Aricept) Slows the natural breakdown of ACh = ↑ Ach Only effective on intact cholinergic neurons SE Insomnia = ↑ Wandering HA Seizures Diarrhea N & V Atrial fibrillation Rivastigimine (Exelon) Galantamine (Reminyl)

19. 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)

20. 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 ADL & Self-care training program

21. 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