Exam 3: Neurocognitive & Somatic disorders Flashcards
(29 cards)
normal aging
-lifespan is now 78 years
-normal for physical decline, with decreased sensory abilities, pulmonary and immune functions
-should be no change in important functions: intellectual function, capacity for change, or productive engagement with life
mental health problems in older adults
-depression, anxiety, and dementia is most common
-complex due to co-morbid medical problems and treatment
-symptoms of somatic disorders imitate or mask psychiatric disorders
-older adults are more likely to report somatic symptoms than psychological ones
-may respond to mental health problems with denial, fear to admit any symptoms
risk assessment of psychological domain for older adults
-depression
-past suicide attempt
-family hx of suicide
-firearms in home
-alcohol or substance abuse
-unusual stress
-burden to family
-social isolation
-chronic medical condition
key concepts
cognition= interrelated abilities like perception, reasoning, judgment, intuition, and memory, allowing one to be aware of themselves within their surroundings
neurocognitive disorders= characterized by declining cognitive function from a previous level of functioning- acquired disorders
delirium vs dementia
delirium: acute cognitive impairment with multiple causes;
dementia: chronic cognitive impairment differentiated by cause, not symptoms:
-cortical dementia: affects cortex (such as Alzheimer’s disease)
-subcortical dementia: affects structures inside the brain and brain stem, symptoms are more localized, often disrupts arousal, attention, and motivation
delirium
disturbance in consciousness and a change in cognition developing over a short period of time
-usually reversible in underlying cause is identified
-serious and treated as a MEDICAL EMERGENCY
-diagnostic: impaired consciousness, less aware of environment, loss of ability to focus, problems in memory, orientation, and language.
-often seen in acute care settings, common in older postoperative patients
-risk factors: existing cognitive impairment, severe illness, advanced age, medications, infection, F+E imbalance, metabolic disturbance, hypoxia, ischemia, brain damage, sensory changes, sleep deprivation, immobilization, psychosocial stress, medications with anticholinergic side effects
interdisciplinary treatment and priorities
EARLY RECOGNITION AND ELIMINATION OR CORRECTION OF THE UNDERLYING CAUSE ARE CRITICAL!!
-symptomatic and supportive measures
-priorities: rule out life-threatening illness, stop all suspected medications, monitor changes in vitals, behavior, and mental status- attend to safety issues.
interventions for delirium
-safe therapeutic environment
-protect patient from physical harm= low bed, guardrails, careful supervision, fall prevention
-maintenance of fluid and electrolyte balance
-adequate nutrition
-prevention of aspiration and skin breakdown
-administration and monitoring of medications, side effects, and drug interactions
-psychoeducation for family and other caregivers
assessment and symptom recognition of delirium
-mental status: fluctuating level of consciousness and reduced awareness of environment
-difficulty focusing and sustaining or shifting attention
-severely impaired memory, especially immediate and recent memory
-behavior: may fluctuate, restless, agitated or lethargic, slow to respond
-disturbed environmental perceptions possible
-thought content may be illogical
-speech may be incoherent and inappropriate
delirium interventions
-frequent interaction and support
-encouragement to express fears and discomforts
-environmental control: adequate lighting, reasonable noise level, easy to read calendar and clocks, frequent verbal orientation, eyeglasses and hearing aids readily available, include familiar personal belongings
-safety management: frequent monitoring, fall prevention
-holistic interventions: aromatherapy, massage, acupuncture, therapeutic touch, hand massage
PRIMARY TREATMENT GOAL= PREVENTION OR RESOLUTION OF THE DELIRIOUS EPISODE WITH RETURN TO PREVIOUS COGNITIVE STATUS
Dementia: Alzheimer’s Disease
degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and eventually death
types:
-early onset: 65 years and younger: rapid progression
-late onset: older than 65 years old: more common
diagnostic criteria of Alzheimer’s
-made on clinical grounds
-verification is only confirmed during autopsy
-essential feature is cognitive decline from a previous level of functioning in one or more of the following domains: executive function, learning and memory, language, perceptual-motor or social cognition
-familial link=risk factor
-risk factors: fewer years of education, prior head injury, down syndrome, metabolic syndrome
typical deficits with alzheimer’s disease
-aphasia: alterations in language ability
-apraxia: impaired ability to execute movement
-agnosia: failure to recognize to identify objects
-disturbance of executive functioning: ability to think abstractly, plan, initiate, sequence, monitor, and stop complex behavior.
alzheimer’s etiology
-beta-amyloid plaques
-neurofibrillary tangles are made of abnormally twisted protein threads disrupting cellular signaling
-reduced neurotransmission and cell death; hippocampal neurons degenerate, increases available acetylcholine- important for cognitive functioning, memory, and information storage
-possible increase in formation of free radicals that can lead to oxidative stress that damages other cellular molecules
-inflammation may damage small blood vessels and brain cells leading to cytotoxicity, such as death of cells
-decreased metabolic activity
nursing management of the biologic domain for Alzheimer’s Disease
-past and present health status
-physical exam, review of systems
-physical functions: ADLs, changes in functional abilities, activity level, need for sensory aids
-self care and assistance to toilet if needed
-promote sleep hygiene
-adapt to patient abilities and interests (activity and exercise)
-nutrition: may need assistance, may not recognize food, may be hyperoral or experience anorexia
-pain: observe for changes in nonverbal communication, facial expressions, hyper-vocalizations, restlessness, agitation
-approach patient calmly, confidently, unhurried
pharmacologic interventions for Alzheimer’s
-acetylcholinesterase inhibitors and NMDA antagonists
-antipsychotics are NOT FDA approved for dementia-related psychosis, with a BBW and increased risk of mortality
-benzodiazepines: may be used with caution, only on short-term basis
-avoid anticholinergic medications for patients if possible
-medications used for aggression, psychomotor agitation, apathy, depression, psychosis, as sleep aids
assessment of alzheimer’s
-personality changes, cognitive status, memory is most dramatic and consistent cognitive impairment, language, executive functioning, visuospatial impairment-deficits in tasks that require sensory and motor coordination, psychotic symptoms such as delusions and/or hallucinations are common, mood changes are depressed, anxiety and/or catastrophic reactions
- apathy, withdrawal, lack of apathy, restlessness, agitation, aggression, aberrant motor behavior such as fidgeting, picking, loud vocalizations, and wandering may indicate underlying physical problem (delirium), disinhibition, hypersexuality, sensitivity to stress and diminished coping abilities.
interventions for alzheimer’s disease
-person centered care
-memory enhancement: reminiscence, pictures
-orientation
-maintenance of language functions
-supporting visuospatial functioning
-manage suspiciousness, illusions, delusions, hallucinations
-manage depression and anxiety: reduce demands, simple routines, reduce number of d=choices
-manage catastrophic reactions: remain calm, reduce stimuli, assure patient of safety, provide information slowly, simple and clear, offer empathy
-manage apathy and withdrawal through engagement
-manage restlessness and wandering: adequate supervision and offer distraction
-manage aberrant behavior with distraction, manage agitation with calm, unhurried, no demands approach, and channel energy into other activities such as walking
-manage disinhibition through gentle redirection
-patient safety interventions adjusted for progression of stages of dementia
-environmental interventions, home visits, milieu management, socialization activities, community actions, family interventions
challenging aspects of care for alzheimer’s
-managing memory loss and confusion
-communication barriers
-behavioral and personality changes
-decision making and problem solving difficulties
delirium vs alzheimer’s
delirium:
-sudden onset
-risk factors of infection, environment, dehydration, substance use, electrolyte imbalance, stroke
-manifestations: acute confusion, agitated, anxiousness, hypervigilant to lethargic concentration, disorganized, can impact memory
-interventions: treat the cause!! safety always, meet physical needs such as nutrition, sleep
-anxiolytics, anti-psychotics for irritability
-cure: TREAT CAUSE- MEDICAL EMERGENCY
alzheimers:
-gradual and progressive development
-risk factors: genetics/family history, advanced age, lifestyle factors
-manifestations: depends on stage- early may not be noticeable to others and initially looks like a hard time focusing, being confused, or mixing up words; moderate is more irritable and more noticeable to others; severe requires assistance and help with ADLs, may be nonverbal with physical difficulties
-interventions: clear, slow, easy communication, face contact, patients, avoid open ended questions, help caregivers with stress
-medications: donepezil, rivastigmine, acetylcholine
-no cure, irreversible, progressive disease
psychosomatic definition
describe, explain, predict the psychological origins of illness and disease; perpetuates stigma that some disorders “psychological” and are not real.
somatization definiton
manifestation of psychological distress as physical symptoms. possibly resulting in functional changes and/or somatic descriptions. historically linked to women, but affects men as well.
somatic symptom disorder
somatization is psychological stress that presents through physical symptoms that can not be explained by any pathology or diagnosis.
characteristics:
-symptoms changeable, diffuse, and complex, variable, moving from one body system to another
-multiple visits to HCP, “provider shopping” avoiding mental health providers
-may eventually become disabled and unable to work
-may undergo multiple surgeries and develop iatrogenic illness
-report same symptoms repeatedly, receive support that otherwise may not be forthcoming, express concern about physical problems inconsistent with severity.
-alexithymia: difficulty identifying and expressing emotions.
DSM-5 diagnostic criteria of somatic symptom disorder
one or more symptoms that cause persistent distress or significant disruption in daily lives for at least 6 months
-excessive thoughts about seriousness of symptoms, feelings such as anxiety about overall health, or behaviors related to the symptoms or health concerns
-although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent, typically for more than 6 months
