Cognitive Disorders Elisa A. Mancuso RNC, MS, FNS Professor.
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Transcript of Cognitive Disorders Elisa A. Mancuso RNC, MS, FNS Professor.
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Cognitive Cognitive DisordersDisorders
Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS
ProfessorProfessor
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DeliriumDelirium Identified cerebral disease or dysfunctionIdentified cerebral disease or dysfunction
– Acute & fluctuatingAcute & fluctuating Impaired cognitionImpaired cognition
– Decision makingDecision making– Problem solvingProblem solving– Interpreting environmentInterpreting environment– Learning new information Learning new information
Disturbed consciousnessDisturbed consciousness– Disoriented to time & placeDisoriented to time & place– Illusions, hallucinations, anxiety, & Illusions, hallucinations, anxiety, & ▲ ▲ sleep sleep
patternspatterns Psychomotor AgitationPsychomotor Agitation
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Delirium EtiologyDelirium Etiology General Medical ConditionsGeneral Medical Conditions
UTIUTI URIURI CHF (Older acutely ill) PNCHF (Older acutely ill) PN Systemic DisturbancesSystemic Disturbances
Fluid/Electrolyte imbalanceFluid/Electrolyte imbalance Thiamine deficiencyThiamine deficiency
Exogenous SubstancesExogenous Substances Heavy metals- Lead (Pb) Mercury (Hg) Heavy metals- Lead (Pb) Mercury (Hg) ↑↑ ↑↑ Coke Coke Heroin Heroin Marijuana Marijuana ETOH ETOH
MedicationsMedications BenzodiazepenesBenzodiazepenes Sedatives/HypnoticsSedatives/Hypnotics AnalgesicsAnalgesics AnticonvulsantsAnticonvulsants DiureticsDiuretics NeurolepticsNeuroleptics AntihypertensivesAntihypertensives DigoxinDigoxin
Resolve underlying cause & condition improves!Resolve underlying cause & condition improves!
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Dementia Dementia Develops slowly 80% IrreversibleProgressive deterioration
Multiple Cognitive DeficitsImpaired short & long term memoryAphasia: ↓Language
Apraxia: ↓ Motor function
Agnosia: Inability to recognize objects
↓ Abstract Thinking
↓ Self-Care
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Senile DementiaSenile Dementia
6% people > age 65 6% people > age 65 oror 30% > age 9030% > age 90Syndrome of acquired, persistent intellectual impairmentSyndrome of acquired, persistent intellectual impairment
Etiology Cerebral hypoxiaCerebral hypoxia Intracranial tumors Intracranial tumors HydrocephalusHydrocephalus MS MS Hypertensive EncephalopathyHypertensive Encephalopathy
Symptoms Short-term memory deficitShort-term memory deficit AphasiaAphasia ConfabulationConfabulation BlockingBlocking ↓ ↓ Abstract thinking Abstract thinking Poor judgment & impulse controlPoor judgment & impulse control Disintegrating personalityDisintegrating personality
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Alzheimer’s Degenerative DementiaAlzheimer’s Degenerative Dementia
70% of all dementia = 4 million people70% of all dementia = 4 million peopleSlow & insidious onsetSlow & insidious onsetProgressive & chronic deteriorationProgressive & chronic deterioration
– 8-15 years from onset8-15 years from onset Women 2x>menWomen 2x>men IrreversibleIrreversible
ACh deficiency =ACh deficiency =↓ neuron impulse↓ neuron impulse ↑ ↑ Aluminum accumulationAluminum accumulation Altered immune system Altered immune system
– ↑ ↑ Ab titers (Protein A-68)Ab titers (Protein A-68) ↑ ↑ Beta AmyloidBeta Amyloid
– Neuronal plaques Neurofibrillary tanglesNeuronal plaques Neurofibrillary tangles– Cortex atrophyCortex atrophy
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Alzheimer’sAlzheimer’s
Predisposing FactorsPredisposing Factors Head traumaHead trauma Genetic: Chromosome # 14, 19 & 21Genetic: Chromosome # 14, 19 & 21 Vascular injury 2 to HTN or cerebral emboliVascular injury 2 to HTN or cerebral emboli Huntington’s ChoreaHuntington’s Chorea Parkinsons DiseaseParkinsons Disease Pick’s DiseasePick’s Disease
– Degeneration of frontal lobeDegeneration of frontal lobe
Creutzfeldt-Jakob DiseaseCreutzfeldt-Jakob Disease– Infectious processInfectious process
Secondary to HIVSecondary to HIV
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Alzheimer’s PhasesAlzheimer’s Phases
Phase I : Forgetfulness (1 year)Phase I : Forgetfulness (1 year)
– Short term memory loss (Absent minded)Short term memory loss (Absent minded)
– Lose things & forget names of peopleLose things & forget names of people
– Pt aware & tries to compensatePt aware & tries to compensate
– Anxious & fearful regarding losing abilitiesAnxious & fearful regarding losing abilities
– FrustratedFrustrated
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Alzheimer’s PhasesAlzheimer’s Phases
Phase II : Confusion (2-12 years)Phase II : Confusion (2-12 years)– HyperoralityHyperorality– Tantrums & WanderingTantrums & Wandering– SundowningSundowning
Afternoon Worsening: Agitation & ConfusionAfternoon Worsening: Agitation & Confusion – Difficulty concentrating Difficulty concentrating yet denies problemyet denies problem
Lost when drivingLost when driving ↓ ↓ Work performanceWork performance Inability to learn new information or recall informationInability to learn new information or recall information
– PerservationPerservation Verbalize same idea repeatedlyVerbalize same idea repeatedly
– AgnosiaAgnosia Failure to identify objectsFailure to identify objects
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Alzheimer’s PhasesAlzheimer’s Phases Phase III- Terminal Dementia (8 mos -2 years)Phase III- Terminal Dementia (8 mos -2 years)
– Severe & significant decline in functioningSevere & significant decline in functioning– ↓ ↓ Memory of major life events & family membersMemory of major life events & family members– RegressionRegression– Poor impulse controlPoor impulse control
↑ ↑ Sexual behaviorSexual behavior– Unable to do ADLs independentlyUnable to do ADLs independently
IncontinentIncontinent– Delusions, Hallucinations, AnxietyDelusions, Hallucinations, Anxiety– Aphasia, Agraphia & ApraxiaAphasia, Agraphia & Apraxia– Final vegetative stateFinal vegetative state
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Nursing InterventionsNursing Interventions
Physical ExamPhysical Exam– R/O any organic causeR/O any organic cause
PET, CT, MRIPET, CT, MRI √ √ Neurofibrillary tangles & atrophy of cortexNeurofibrillary tangles & atrophy of cortex
Hx of onsetHx of onset Family, friends & colleaguesFamily, friends & colleagues
Assess Mental StatusAssess Mental StatusOrientationOrientation Affect Affect
Concentration Memory Coordination Concentration Memory Coordination Abstract Thinking Abstract Thinking
JudgmentJudgment Sensory Perception Sensory Perception
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Nursing InterventionsNursing Interventions
PALMERPALMER– PPerceptionerception– AAttention Spanttention Span– LLanguageanguage– MMemoryemory– EEmotional Controlmotional Control– RReasoning & Judgmenteasoning & Judgment
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Nursing InterventionsNursing Interventions
# 1 Patient Safety!# 1 Patient Safety!– ID braceletID bracelet– Notify Police & local storesNotify Police & local stores– Recent photo & all contact #sRecent photo & all contact #s– Physical EnvironmentPhysical Environment
Security system in homeSecurity system in home ChildproofChildproof Consistent & unclutteredConsistent & uncluttered ↓ ↓ StimulationStimulation Well lit & handrailsWell lit & handrails
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Nursing InterventionsNursing Interventions Psychological SupportPsychological Support
– Supportive touchSupportive touch– Promote interactionPromote interaction
Group activityGroup activity
– Reminiscence therapyReminiscence therapy Life reviewLife review Stimulates remote memoryStimulates remote memory Promotes Promotes ↑self-esteem↑self-esteem
– DistractionDistraction Music therapyMusic therapy
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Nursing InterventionsNursing Interventions ADLsADLs
– Allow Pt to make simple choices = Allow Pt to make simple choices = ↑ control↑ control– Break down tasks to short, simple steps = KISSBreak down tasks to short, simple steps = KISS– Give verbal & visual cuesGive verbal & visual cues– Clear expectationsClear expectations– Allow ample time to performAllow ample time to perform
Velcro, elastic, large zippers & sneakersVelcro, elastic, large zippers & sneakers
ExerciseExercise– ROM PT & daily walksROM PT & daily walks– ↑ ↑ activity in day ↓ wandering @ nightactivity in day ↓ wandering @ night
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Nursing InterventionsNursing Interventions NutritionNutrition
– Keep mealtimes consistentKeep mealtimes consistent– Provide finger foodsProvide finger foods– Balance diet withBalance diet with↑ calorie liguids↑ calorie liguids– Weigh weeklyWeigh weekly– Use bowls & spoonsUse bowls & spoons Bibs & drop clothsBibs & drop cloths
EliminationElimination– √ √ I & OI & O– ↓ ↓ Fluids @ bedtimeFluids @ bedtime– Toilet @ regular intervals q 2hToilet @ regular intervals q 2h– Incontinent productsIncontinent products
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MedicationsMedicationsHelp delay or prevent worsening of symptoms
Start low & go slow with dosages!
Cholinesterase InhibitorsCholinesterase Inhibitors Donepezil (Aricept)Donepezil (Aricept)
– Slows the natural breakdown of ACh = Slows the natural breakdown of ACh = ↑ ACh↑ ACh– Only effective on intact cholinergic neuronsOnly effective on intact cholinergic neurons– SESE
Insomnia = Insomnia = ↑ Wandering↑ Wandering Diarrhea Diarrhea N & VN & V
Rivastigimine (Exelon)Rivastigimine (Exelon)– Transdermal PatchTransdermal Patch– SESE
N & V N & V Abdominal painAbdominal pain ↓↓AppetiteAppetite
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Cholinesterase InhibitorsCholinesterase Inhibitors
Galantamine (Reminyl, Razadyne)Galantamine (Reminyl, Razadyne)– SE
N & V ↓Appetite Dizziness
Memantine (Nemenda)Memantine (Nemenda)– ↑ ↑ Availabilty of AChAvailabilty of ACh– Target symptoms @ mod Target symptoms @ mod →→ severe stage severe stage– Time limited benefitsTime limited benefits– SESE
↑↑ ↑↑ BPBP PainPain HAHA VomitingVomiting ConstipationConstipation
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Symptomatic ManagementSymptomatic Management AnxiolyticsAnxiolytics
Short term use to Short term use to ↓ anxiety ↓ anxiety BuSpar BuSpar best = best = ↓ ↓ cognitive & psychomotor SEscognitive & psychomotor SEs
AntipsychoticsAntipsychotics ↓ ↓ AgitationAgitation ↓ Aggression ↓ Aggression ↓ Hallucinations ↓ Hallucinations ↓ ↓ Paranoid thinkingParanoid thinking Zyprexia & SeroquelZyprexia & Seroquel best = ↓ EPS best = ↓ EPS
AntidepressantsAntidepressants ↑ ↑ Sleeping ↑ Thinking ↑ Memory ↑ AppetiteSleeping ↑ Thinking ↑ Memory ↑ Appetite TCATCA ¼ -1/2 dose ¼ -1/2 dose
– Bupropion (Wellbutrin) Vanlafaxine (Effexor) SSRIsSSRIs
– No Fluoxetine (Prozac) inhibits liver enzymes & No Fluoxetine (Prozac) inhibits liver enzymes & ↑ ↑ serum levels of other medsserum levels of other meds
– Paroxetine (Paxil) Citalopram (Celexa)
AnticonvulsantsAnticonvulsants ↓ ↓ Impulsivity & aggressionImpulsivity & aggression Valproic Acid (Depakote) & Carbamazapine (Tegretol)Valproic Acid (Depakote) & Carbamazapine (Tegretol)
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Multidisciplinary ApproachMultidisciplinary Approach Speech TherapistSpeech Therapist
– Restore swallowingRestore swallowing– Delay aphasiaDelay aphasia
Physical TherapistPhysical Therapist– ““Use it or lose it”Use it or lose it”– Retain strength & memoryRetain strength & memory– ImproveImprove large & fine motor skills large & fine motor skills
Occupational TherapistOccupational Therapist– Sensory & Brain stimulationSensory & Brain stimulation– ADL & Self-care training programADL & Self-care training program
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Multidisciplinary ApproachMultidisciplinary Approach Social WorkerSocial Worker
– Individual & Group TherapyIndividual & Group Therapy– Family SupportFamily Support
Sandwich generationSandwich generation ↑ ↑ Caretaking demands & multiple rolesCaretaking demands & multiple roles Coping with feelings of personal lossCoping with feelings of personal loss Anticipatory GrievingAnticipatory Grieving Assistance from all relevant agenciesAssistance from all relevant agencies Alzheimer's Alzheimer's AssociationAssociation
– Community ResourcesCommunity Resources Respite careRespite care Day Care CentersDay Care Centers Residential FacilitiesResidential Facilities Specialized Alzheimer’s unitsSpecialized Alzheimer’s units