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Delirium, Dementias, and Related Disorders

Delirium, Dementias, and Related Disorders

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Delirium, Dementias, and Related Disorders

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  1. Delirium, Dementias, and Related Disorders Chapter 29

  2. Key Concepts • Cognition • System of interrelated abilities, such as perception, reasoning, judgment, intuition and memory • Allows one to be aware of oneself • Memory • Facet of cognition, retaining and recalling past experiences • Delirium • Acute cognitive impairment caused by medical condition • Dementia • Chronic, cognitive impairment • Differentiated by cause, not symptoms

  3. DeliriumClinical Course • Disturbance in consciousness and a change in cognition • Develops over a short period of time • Usually reversible if underlying cause identified • Serious, should be treated as an emergency

  4. DeliriumDiagnostic Criteria • Impairment in consciousness - key diagnostic criteria • Children - can be related to medications or fever • Elderly - most common in this group, often mistaken as dementia

  5. DeliriumEpidemiology & Risk Factors • Prevalence rates from 10-30% of patients • In nursing homes, prevalence reaching 60% of those older than the age of 75 years • Occurs in 30% of hospitalized cancer patients • 30-40% of those hospitalized with AIDS • Higher for women than men • Common in elderly, post-surgical patients

  6. DeliriumEtiology • Complex and usually multidimensional • Most commonly identified causes: • Medications • Infections • Fluid and electrolyte imbalances • Variety of brain alterations • Reduction in cerebral functioning • Damage of enzyme systems, blood brain barrier or cell membranes • Reduced brain metabolism • Imbalance of neurotransmitter • Raised plasma cortisol level • Involvement of white matter

  7. Types • Due to General Medical Condition • Substance-Induced • Substance-Intoxication • Substance-Withdrawal • Multiple Etiologies

  8. Medications • Anticholinergic • Antihistamines, Chlorpheniramine, Ornade & Teldrin), antiparkinsonian drugs (Cogentin, Akineton, atropine, diphenhydramine, phenothiazines, promethazine (Phenergan), scopolamine, TCA • Anticonvulsant • Phenobarbital, phenyton (Dilantin), sodium valproate (Depakene)

  9. Medications • Anti-inflammatory • Corticosteroids, ibuprofen, indomethacin (Indocin), naproxen (Naprosyn) • Antiparkinsonian • Amantadine (Symmetrel), carbidopa (Sinemet) • Antituberculous • Levodopa (Larodopa), isoniazid, rifampin

  10. Medications • Analgesic • Opiates, salicylates, synthetic narcotics • Cardiac • Beta blockers, propranolol (Inderal), clonidine (Catapres), digitalis (Digoxin, and Lanoxin), lidocaine (Xylocaine), methyldopa (Aldomet), quinidine, procainamide (Pronestyl)

  11. Medications • Sedative/Hypnotic • Barbiturates, benzodiazepines • Sympathomimetic • Amphetamines, phenylephrine, phenylpropanolamine • OTC • Compoz, Excedrin PM, Sleep-Eze, Sominex

  12. Medications • Miscellaneous • Antiviral, aminophylline, amphotericin (antifungal), bromides, cephalexin (Keflex), chlorpropamide (Diabinese), cimetidine (Tagamet), disulfram (Antabuse), lithium, metronidazole (Flagyl), theophylline, timolol opthalamic

  13. Physiological • Fluid/kidney • Dehydration, Hypocalcemia, Hypokalemia, Abnormal sodium, Low serum albumin, Elevated BUN, Elevated creatinine, Azotemia, Proteinuria, CRD • Cardiac/Respiratory • Hypotension, CVD, CHF, AA, Elevated PT, Low hematocrit, Respiratory insufficiency, Noncardiac thoracic surgery

  14. LABS • BUN • 7-18mg/dL or 2.5-6.4 mmol/L • >60 8-20 mg/d> or 2.9-7.5 mmol/L • Creatinine Clearance • Men 94-140 mL/min/1.72 • Women 72-110mL/min/1.73m • Serum Albumin • Normal 3.5-5.0g/dL

  15. Labs • Hyponatremia • <12mEq/L • Hypocalcemia • <4.65-5.28mg/dL • Hypokalemia • <2.8mEq/L • Elevated PT • Critical Value >30 seconds.

  16. Physiological • Metabolism/Temperature • Metabolic disturbances, Nutritional deficiencies, Abnormal Glucose, • Normal Fasting Adults: <-110 mg/dL • Elevated AST/SGOT • Normal : 8-20 U/L • Abnormal Temperature • Age, gender • Age 65 and older (higher incidence over 80) • Male • Limited social contact, Admission from an institution

  17. Physiological Infection and Trauma • Symptomatic infection • Urinary tract infection • Respiratory infection • Elevated WBC • Emergency Admission • Fracture • Falls • Orthopedic surgery • Combination illnesses

  18. Physiological • More than 4 medications • Drugs with anticholinergic or CNS effects • Hypoxia/Ischemia

  19. Interdisciplinary Treatment & Priorities • Interdisciplinary treatment • Elimination or correction of the underlying cause • Symptomatic and supportive measures • Priorities • Safety • Pay attention to life-threatening disorders. • Rule out life-threatening illness. • Stop all suspected medications. • Monitor vital signs.

  20. Nursing Management Biologic Domain Assessment • Identify normal • Past and present health status • Description of onset, duration, range and intensity of symptoms • Presence of chronic physical illness, dementia, depression, etc. • Physical exam and review of symptoms • Special attention to lab values CBC, BUN, creatinine, electrolytes, liver function and O2 saturation • Physical functions - ADLs, activity level, pain

  21. Nursing ManagementBiologic DomainPharmacologic Assessment • Substance abuse history • Assess for combinations of medications • OTC medication

  22. Delirium: Biologic DomainNursing Diagnosis • Acute confusion • Disturbed thought processes • Disturbed sensory perception • Hyperthermia • Acute pain • Risk for infection • Disturbed sleep pattern

  23. DeliriumBiologic Nursing Interventions • Safety • Protection from physical harm • Low beds, guard rails and careful supervision • Maintaining fluid and electrolyte balance • Adequate nutrition • Prevent aspiration • Prevent decubitus ulcers • Pharmacologic • Treatment of the behavior must consider potential anticholinergic side effects. • Lowest possible dose

  24. DeliriumPsychological DomainAssessment • Cognitive changes with rapid onset (several scales see page 678) • Fluctuations in level of consciousness, reduced awareness of environment • Difficulty focusing, sustaining or shifting attention • Severely impaired memory • May be disoriented to time and place, but rarely to person • Environmental perceptions altered • Illogical thought content • Behavior change • Hyperkinetic delirium: psychomotor hyperactivity, excitability, hallucinations • Hypokinetic delirium: lethargic, somnolent, apathetic

  25. Delirium: Psychologic DomainNursing Diagnosis • Acute confusion • Disturbed thought process • Ineffective coping • Disturbed personal identity

  26. DeliriumPsychological Nursing Interventions • Frequent interaction • Support for confusion or hallucinations • Encouraged to express fears and discomforts • Adequate lighting • Easy-to-read calendars and clocks • Reasonable noise level • Frequent verbal orientation • Devices available - eye glasses and hearing aids

  27. Delirium Social DomainAssessment • Assessment of living arrangement • Cultural and educational background considered • Presence of family support • Family interactions

  28. Delirium: Social DomainNursing Diagnosis • Interrupted family processes • Ineffective protection • Ineffective role performance • Risk for injury

  29. DeliriumSocial Nursing Interventions • Safe environment • Predictable, orienting environment • Avoid physical restraint • Presence of family members can be helpful

  30. Evaluation • Correction of underlying physiologic alteration • Resolution of confusion • Family member verbalization of understanding • Prevention of injury

  31. Sudden onset Fluctuating course  consciousness  attention  cognition Hallucinations  activity Incoherent speech Involuntary motor movement Illness, toxicity Insidious onset Stable course Clear Clear  cognition May be present Normal Normal Normal Normal Delirium Dementia

  32. Dementia Alzheimer’s Type • Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death • Types • Early-onset (65 years and younger) • Rapid progression • Late-onset (over 65) • Stages: mild, moderate, severe (Figure 29-1)

  33. Dementia/Alzheimers Progression

  34. Diagnosis of AD • Essential feature - multiple cognitive deficits • One or more of the following: • Aphasia (alterations in language) • Apraxia (impaired ability to execute movement) • Agnosia (failure to recognize or identify objects) • Disturbance of executive functioning

  35. Epidemiology • 4 millions Americans • 6 million by the year 2040 • 10% over 65 years, 47.2% over 85 ears • Highest prevalence over the age of 85 • Twice as common in women

  36. Risk Factors • Age • Gender • Can run in families • Low educational levels (for women)

  37. Etiology • Neuritic plaques (extracellular lesions) Highest density in temporal and occipital lobes, intermediate in parietal lobes, lowest in frontal and limbic cortex • -amyloid protein • Apolipoprotein A cores • Neurofibrillary tangles – initially in limbic then progress to cortex • Apolipoproprotein E • Cholinergic hypothesis • Acetylcholine is associated with cognitive function/disruption damages memory • ACh is reduced • Lowered Norepinephrine – loss of cells in locus ceruleus • Lowered Serotonin – neuronal loss in raphe nuclei • Genetic factors • Roles of chromosome 1, 14 and 21 • Oxidative stress and free radicals • Inflammation

  38. Interdisciplinary Treatment • Confirmation of the diagnosis • Establishment of baseline levels in functional sphere • Establishment of a therapeutic relationship with patient and family • Management of cognitive symptoms • Delaying cognitive decline • Treatment of non-cognitive symptoms - psychosis, mood symptoms and agitation • Support caregivers

  39. Priority Care Issues • Priorities will change throughout the course of the disorder. • Initially, delay cognitive decline. • Later, protect patient from hurting self. • Later, physical needs become the focus of care.

  40. Family Response to AD • Family can be devastated. • Caregiver’s health and well-being are often compromised. • Caregiver distress is a major risk factor. • Caregiver burden often leads to nursing home placement. • Caregiver support can delay nursing home placement.

  41. Nursing ManagementBiologic DomainAssessment • Past and present health status (compare to typical) • Physical examination and review of systems • Vital signs, neurologic status, nutritional status, bladder and bowel function, hygiene, skin integrity, rest and activity, sleep patterns, and fluid and electrolyte balance • Physical functions • Self-care • Sleep-wake disturbances • Activity and exercise • Nutrition • Pain

  42. Dementia: Biologic DomainNursing Diagnosis • Imbalanced nutrition • Self-care deficits (feeding, bathing/hygiene, toileting, constipation) • Impaired swallowing • Bowel incontinence • Impaired urinary elimination • Functional incontinence • Deficient fluid volume

  43. DementiaBiologic Nursing Interventions • Self-care • Maintaining independence as much as possible • Oral hygiene • Nutritional • Monitoring patient’s weight, oral intake and hydration • Well-balanced meals • Observation for swallowing difficulties • Sleep interventions • Activity and exercise - Balance activity with sleep. • Pain and comfort management - Assess carefully, and do not rely on verbalizing pain. • Relaxation

  44. Pharmacologic Interventions • Acetylcholinesterase inhibitors (AChEI) • Donepezil (Cognex) • Rivastigmine (Exelon) • Galantamine (Reminyl) • Used to delay cognitive decline • Most common side effects: nausea, vomiting • Antiinflammatory - Ibuprofen • Antipsychotics • Antidepressants and mood stabilizers • Antianxiety medications - used with caution • Avoid medications with anticholinergic side effects.

  45. DementiaPsychological DomainAssessment • Responses to mental health problems - personality changes • Cognitive status (MMSE and others) • memory – visuospatial • language – executive functioning • Psychotic symptoms • suspiciousness, delusions and illusions • hallucinations

  46. DementiaPsychological DomainAssessment (cont.) • Mood changes • Depression • Anxiety • Catastrophic reactions • Behavioral responses • Apathy and withdrawal • Restlessness, agitation and aggression • Aberrant motor behavior • Disinhibition • Hypersexuality • Stress and coping skills

  47. Dementia: Psychological DomainNursing Diagnosis • Impaired memory • Disturbed thought processes • Chronic confusion • Disturbed sensory perception • Impaired environmental interpretation syndrome • Risk for violence • Risk for loneliness • Risk for caregiver role strain • Ineffective individual coping • Hopelessness • Powerlessness

  48. DementiaPsychological Nursing Interventions • Therapeutic relationship • Interventions for cognitive impairment • Validation therapy • Memory enhancement • Orientation • Maintenance of language functions • Supporting visuospatial functioning • Interventions for psychosis • Management of suspicious, illusions, delusions • Management of hallucinations

  49. DementiaPsychological Nursing Interventions • Interventions for alterations in mood • Management of depression (Do not force activities, but encourage them.) • Management of anxiety by helping patient deal with stress • Remaining calm during catastrophic reactions, minimizing environment distractions, speaking slowly, being reassuring

  50. DementiaPsychological Nursing Interventions • Interventions for behavior problems • Keep close contact with family; help engage patient. • Do not interrupt wandering behavior, but identify pattern. Determine if he/she is confused and can not find way; walk with patient, then re-direct. • Distract for picking in air, wringing hands. • Determine meaning of vocalizations. • Determine antecedents to agitated behavior. • Reduce stimulation to minimize disinhibition.