MH Ch. 23- Neurocognitive Disorders PDF

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Varcarolis' Foundations. of Psychiatric Mental Health Nursing 8th Edition...

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Mental Health Chapter 23- Neurocognitive Disorders ● Cognitive functioning involves a variety of domains. Attention and orientation are basic lower-level cognitive domains. ● High-level cognitive domains are more complex & include an ability to do the following: ○ Plan and problem solve (executive function) ○ Learn & retain information in long term memory ○ Use language ○ Visually perceive the environment ○ Read social situations (social cognition) ● 3 main neurocognitive classifications are: ○ Delirium ■ Short term & reversible ○ Mild neurocognitive disorders ■ May or may not progress to being major ■ Decline in cognitive functioning ○ Major neurocognitive disorders. ■ Commonly referred to as dementia (progressive and irreversible) ■ Decline in cognitive functioning ● DELIRIUM ○ Epidemiology ■ Delirium- common complication of hospitalization, esp. in older patients ■ Over 65 years of age, occurs in up to 50% ○ Risk Factors ■ Always due to underlying physiological causes (multifactorial & dynamic interplay of factors) ■ BOX 23.1 ● Cognitive impairment, older age, severity of disease, infection, multiple comorbidities, polypharmacy, ICU, unaddressed orientation, visual, or hearing issues, fractures, surgery, stroke, aphasia (loss of ability to understand or express speech), vision impairment, restraint use, change in hospital rooms. ■ KEY: recognizing and investigating potential causes ASAP ○ Clinical Picture ■ Delirium: an acute cognitive disturbance and often-reversible condition that is common in hospitalized patients, especially older patients. ■ Characterized as a syndrome (a constellation of symptoms) ■ A MEDICAL EMERGENCY! ● Requires immediate attention to prevent irreversible and serious damage

● Associated with increased morbidity and mortality and can have lasting long-term consequences such as permanent cognitive decline ■ Characterized as a syndrome (constellation of symptoms) ■ Cardinal Symptoms: ● Inability to direct, focus, sustain, and shift attention; ● An abrupt onset with clinical features that fluctuate with periods of lucidity; ● Disorganized thinking and poor executive functioning ■ Other: disorientation (time and place, but rarely person), anxiety, agitation, poor memory, and delusional thinking ■ When an older adult patient takes multiple medications daily and over 2 days, the patient develops confusion, slurred speech, an unsteady gait, and fluctuating levels of orientation, these findings are most characteristic of delirium. ○ DSM-5 Criteria for Delirium ■ A.) Disturbance in attention & awareness ■ B.) Disturbance develops over a short period of time (hours to a few days), a change from baseline attention and awareness, and fluctuates in severity throughout the day. ■ C.) Additional disturbance in cognition (memory deficit, disorientation) ■ D.) Disturbances in A & C are not better explained by another preexisting, established or evolving neurocognitive disorder ■ E.) Evidence from the H & P exam or lab findings that disturbance is a direct physiological consequence of another medical condition ■ *Substance intoxication delirium: should be made instead of substance intoxication when the symptoms in A & C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. ○ Application of the Nursing Process ■ Assessment ● Perform mental and neurological status examinations, as well as physical exam ● Additional info from family/friends ● Medication regimen should be reviewed carefully (drug interactions/toxicity profiles) ● Lab results reviewed (bloodwork and urinalysis) ■ Overall Assessment ● Consider when a patient abruptly demonstrates a reduced clarity of awareness of environment ● May have to repeat questions (attention will wander) ● Conversation more difficult due to irrelevant stimuli distractions

● May have difficulty orienting (first time, then place, last to person) ● Orientation to person usually intact ● Disorientation and confusion worse at night and early morning ■ Cognitive and Perceptual Disturbances ● Patients are distracted, unable to focus, and exhibit memory impairment ● Mild delirium: memory deficits are noticeable only on careful questioning ● Severe delirium: memory problems usually take the form of obvious difficult in processing and remembering recent events ● Perceptual disturbances common ● Illusions: errors in perception of sensory stimuli (cord of window blind as a snake- you can explain and clarify illusions for them) ○ If a patient is experiencing visual and auditory illusions, use the patient’s glasses and hearing aids to help clarify sensory perceptions. Do not put clocks in the room because without glasses, the clocks will be pointless. ● Hallucinations: false sensory perception occurring without a corresponding sensory stimulus (5 senses) ○ Visual hallucinations common in delirium ○ Tactile hallucinations also present ○ Auditory hallucinations common in schizophrenia ● Individual is generally aware something is very wrong ● When hallucinations are present, the nurse should acknowledge the patients feelings and state the nurses perception of reality, but not argue. “I don’t see any bugs, but I can tell you are frightened. I will stay with you.” ■ Physical Needs ● May want to go home OR think the facility IS home ● Wandering, pulling out IVs and catheters, falling out of bedcommon dangers need nursing interventions ● Patients experiencing delirium have difficulty processing stimuli in the environment, and confusion magnifies the ability to recognize reality. ● Make environment as simple as possible ○ Provide a well-lit room without glare or shadows. Limit noise and stimulation. A quiet, shadow-free room offers an environment that produces the fewest sensory perceptual distortions for a patient with cognitive impairment associated with delirium. ● Short periods of social interaction- help reduce anxiety and

misperceptions ● Autonomic signs: tachycardia, sweating, flushed face, dilated pupils, elevated BP (present in delirium)- monitor & document ● Changes in sleep-wake cycle (complete reversal of day & night sleep-wake cycle can occur) ● Level of consciousness- range from lethargy to stupor or from semi-coma to hypervigilance ● Hypervigilance: extraordinarily alert, and their eyes constantly scan the room ● ALWAYS suspect meds as a potential cause of delirium, esp if there is polypharmacy and/or use of psychoactive agents ● Assess all meds patient is taking ■ Moods & Behaviors ● May change dramatically in a short period ● May display motor restlessness (agitation) or be “quietly delirious” and appear calm & settled ● Delirium considered hyperactive (with agitation) ● Delirium considered hypoactive (no agitation) ● Mood swings may go from fear, anxiety, euphora, depression and apathy ○ Assessment Guidelines- Delirium ■ 1. Do not assume that acute confusion in older person is due to dementia ■ 2. Assess for acute onset and fluctuating levels of awareness ■ 3. Assess person’s ability to attend to immediate environment ■ 4. Establish the person’s usual level of cognition by interviewing family/caregivers. ■ 5. Assess for past cognitive impairment ■ 6. Identify disturbances in physiological status (infection, hypoxia, pain) ■ 7. Identify physiological abnormalities in record ■ 8. Assess vital signs, LOC, and neuro ■ 9. Assess potential for injury (falls and wandering) ■ 10. Maintain comfort measures (pain, cold, positioning) ■ 11. Monitor situation factors and worsen or improve symptoms ■ 12. Assess for availability of immediate medical interventions ○ Nursing Diagnosis ■ Safety needs are a priority ■ Risk for injury ● Priority for a patient with fluctuating levels of consciousness, disturbed orientation, and visual and tactile hallucinations ■ Acute confusion ■ Fear (never leave patient alone)

■ Risk for deficient fluid volume ■ Distrubed sleep pattern/sleep deprivation ■ Impaired verbal communication ■ Self-care deficits and impaired social interaction ○ Outcomes ■ Patient will return to the premorbid level of functioning: ● Patient will remain safe and free from injury while in hospital ● Patient will be A+Ox4 ● Patient will remain free from falls and injury while confused with aid of nursing safety measures ○ Planning ■ Does the person have the necessary visual and auditory aids? ■ Are there family members available to stay with the patient? ■ Does the environment provide visual cues as to time of day and season of year? ■ Has the person experienced continuity of care providers? ○ Intervention (BOX 23.2)

■ Keep the patient safe while attempting to identify cause ■ If underlying disorder is corrected, complete recovery possible ● Goals for a patient experiencing fever and dehydration will focus on returning to premorbid levels of function. ■ Nursing concerns:

● Preventing physical harm due to confusion, aggression, or electrolyte & fluid imbalance ● Minimizing use of restraints because they increase confusion ● Assisting with proper health management to eradicate the underlying cause ● Using supportive measures to relieve distress ■ If underlying cause of delirium not treated, permanent brain damage may ensue ■ Judicious use of antipsychotic or antianxiety agents: useful in controlling behavioral symptoms ● MILD AND MAJOR NEUROCOGNITIVE DISORDERS ○ Dementia: ■ A broad term to describe progressive deterioration of cognitive functioning and global impairment of intellect. A term that does not refer to a specific disease, but a collection of symptoms. ■ DSM-5 incorporates dementia into diagnostic categories of mild and major neurocognitive disorders ■ Mild: impairments do NOT interfere with essential ADLs, ■ Progressive: become major neurocognitive disorders because they interfere with ADLs and independence. ● Patients with cognitive impairment should perform all tasks of which they are capable. ● Characterized by: memory deficits ○ A patient with moderately severe dementia has memory loss that begins to interfere with activities. Using a label on the bathroom door is an intervention. ○ Therapeutic communication for family members: It is disappointing when someone you love no longer recognizes you. ○ A patient with severe dementia no longer recognizes family members and becomes anxious and agitated when they attempt reorientation. The nurse should recommend the family members focus interaction on familiar topics. ○ DSM-5 Criteria for Major Neurocognitive Disorder

■ A. Evidence of significant cognitive decline from previous level of performance in one or more cognitive domains ● 1. Concern of the individual, knowledgeable informant, or clinician that there has been significant decline in cognitive function ● 2. Substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing ■ B. Cognitive deficits interfere with independence in everyday activities ■ C. Cognitive deficits do not occur exclusively in the context of delirium ■ D. Cognitive deficits are not better explained by another mental disorder ● TABLE 23.1 ● ALZHEIMER’S DISEASE ○ Epidemiology ■ Attacks indiscriminately: men & women, various ethnicities, rich/poor, varying IQs ■ Women make up ⅔ of people with dementia (live longer than men) ■ Disease can occur at a younger age (early onset) ■ 75-84 years old; MOST with disease are 65+ (late onset) ○ Risk Factors ■ Biological Factors ● Genetics: ○ Increased risk for those with immediate family member ○ 3 known genetic mutations that guarantee a person will develop Alzheimer’s (less than 1% of all cases) ○ Susceptibility gene for late onset: makes the protein apolipoprotein E (APOE) ■ Supports lipid transport & injury repair in brain ● Neurobiological: ○ Neuronal degeneration (begins in hippocampus- recent memory, then spreads to cerebral cortex- problem solving & higher order cognitive functioning) ○ 2 processes contribute to cell death: ■ 1. Accumulation of protein beta-amyloid outside the neurons (interferes with synapses) ■ 2. Accumulation of the protein tau inside the neurons (forms tangles that block flow of nutrients) ● Cardiovascular Disease ○ Inactivity, high cholesterol, diabetes and obesity ● Head Injury & Traumatic Brain Injury ○ Boxers and football players ■ Environmental Factors

● Social Engagement and Diet ● Remain mentally and socially active, consume a healthy diet ○ Clinical Picture ■ Alzheimer’s accounts for 60-80% of all dementias ■ NEED to distinguish between normal forgetfulness and memory deficit of Alzheimer’s (TABLE 23.2) ■ Severe memory loss is NOT a normal part of growing older ■ Slow, mild cognitive changes associated with aging should not impede social or occupational functioning ■ Dementia is marked by progression deterioration in other cognitive functions such as problem solving and learning new skills and a decline in the ability to perform ADLs. ○ PROGRESSION OF ALZHEIMER’S DISEASE ■ According to the stage of degenerative process ■ 3 stages (TABLE 23.3) ○ SIGNS OF ALZHEIMER’S ■ Memory changes that disrupt life ■ Difficulty completing familiar tasks ■ Trouble understanding visual images/spatial relationships ■ Misplacing things and losing ability to retrace steps ■ Withdrawal from social and work activities ■ Challenges in planning/solving problems ■ Confusion with time and place ■ New problems with words in speaking/writing ■ Decisions/poor judgment ■ Changes in mood and personality

● Mild ○ Roughly corresponds to the DSM-5 criteria for MILD neurocognitive disorders ○ Person loses energy, drive, initiative and has difficulty learning new things ○ Personality and social behavior remain intact ○ Individual may continue to work, but the extent of the dementia becomes evident in new or demanding situations ○ Depression may occur early on, but usually resolves over time ● Moderate ○ Related to the DSM-5 criteria for MAJOR neurocognitive disorder ○ EX. An older adult driving to the store, but not knowing how to get home & wearing a heavy coat & hat in July. ○ Deterioration is evident. Memory loss may include the inability to remember addresses or date. ● Severe ○ Related to the DSM-5 criteria for MAJOR neurocognitive disorder ○ Communicating pain becomes difficult; personality changes take place; need extensive help with ADLs ○ Veggie table: loses ability to respond to environment, carry on conversation, and eventually control movement ○ ■ More severe symptoms appear as disease progresses

● Agnosia: the inability to identify familiar objects/people, even spouse ● Apraxia (common): a person needs repeated instructions and directions to perform simple tasks. ● Incontinence ○ Application of the Nursing Process ■ Assessment ● Commonly characterized by progressive deterioration of cognitive functioning ● Initial: may be so subtle and insidious (proceeding in a gradual, subtle way, but with harmful effects) ● Confabulation: the creation of stories or answers in place of actual memories to maintain self-esteem (NOT the same as lying; it’s unconscious) ○ EX: having dinner with president ● Perseveration: persistent repetition of a word, phrase, or gesture ● Agraphia: diminished ability & eventual inability to read/write (occurs early in Alzheimer’s) ● Aphasia: loss of language ability, reduced to babbling/mutism ● Apraxia: loss of purposeful movement in the absence of motor or sensory impairment. ● Agnosia: loss of sensory ability to recognize objects ○ EX: saying a smoke detector is going off but it’s the phone ringing ● Hyperorality: the tendency to taste, chew, and put everything in mouth ● Hypermetamorphosis: the urge to touch everything ● Sundowning: the tendency for mood to deteriorate and agitation increase in the later part of day or at night ● Memory impairment: initially, a person has difficulty remembering recent events. Gradually, deterioration progresses to include recent and remote memory ● Disturbances in executive functioning (planning, organizing, abstract thinking) ● Emotions begin to diminish ■ Diagnostic Tests ● Many individuals with Alzheimer's disease also meet criteria for depressive disorder ● Dementia and depression or dementia and delirium CAN coexist (TABLE 23.4) ● Brain imaging with computed tomography scan (CT) & Positron

emission tomography (PET) ○ Both reveal brain atrophy and rule out conditions such as neoplasms ● Mental status questionnaires (Mini-Mental State Examination): to identify deterioration in mental status and brain damage (important part of assessment) ● Obtain complete medical & psychiatric history, meds used, etc ○ Assessment Guidelines- Alzheimer’s Disease ■ 1. Evaluate person’s current level of cognitive & daily functioning ■ 2. Identify any threats to person’s safety & security; arrange for reduction ■ 3. Evaluate the safety of home environment ■ 4. Review medications (including herbs) ■ 5. Interview family to gain picture of person’s background ■ 6. Explore how well the family is prepared & informed about dementia progress ■ 7. Discuss with family members how they are coping ■ 8. Review resources available to family ■ 9. Identify needs of family for teaching (sundowning) ○ Nursing Diagnosis ■ Risk for injury (always priority) ■ Impaired verbal communication ■ Interrupted family processes, anticipatory grieving, disabled family coping ■ Impaired environmental interpretation syndrome ■ Impaired memory ● A patient with stage 3 Alzheimer's disease tires easily & prefers to stay home rather than attend social activities. Spouse grocery shops because the patient forgets what to buy. ● Memory impairment begins at stage 2 and progresses in stage 3. ■ Confusion ■ TABLE 23.5- types of everyday problems ○ Outcomes ■ Self care needs, impaired environmental interpretation, chronic confusion, ineffective individual coping, and caregiver role strain (**TABLE 23.6**)

○ Interventions

■ BOX 23.3 ○ Person-Centered Care Approach ○ Health teaching and health promotion ■ Patient-centered care: based on an ethical position that personhood in dementia remains and should be honored. Also focused on forming meaningful relationships with the person who has dementia and their caregivers. ■ Developing meaningful relationships maintains the unique identity of the person and promotes well-being. ■ There is evidence that a person-centered approach to care can significantly decrease agitation in people with dementia living in residential care settings. ○ Health teaching and health promotion ■ Educate families about strategies for communicating and structuring selfcare activities ■ Refer to community support; alzheimer’s association, community resource finder ■ Families need information, support, and legal/financial guidance ■ Need proper referrals by social workers; include advance directives, durable power of attorney, guardianship, and conservatorship in communication with family.

○ PHARMACOLOGICAL INTERVENTIONS

■ The benefits of these medications wane after 1-2 years so patients should weight the potential side effects against the potential benefits ■ Cholinesterase Inhibitors ● A deficiency of acetylcholine has been linked- medications aimed at preventing its break down has been developed ● Drugs work by preventing acetylcholinesterase (or cholinesterase) from breaking down acetylcholine in the brain ● An increased concentration of acetylcholine leads to temporary improvement of some symptoms of Alzheimer’s ● Produce small, but short-lived improvements in cognitive functioning ● MINIMAL benefit after 1 year ● Risk of side effects doubles in 85+ ● **Side effects: ALL have the potential to cause nausea, diarrhea and vomiting; Bradycardia and syncope (LOOK AT THE TABLE!) ● CAUTION when taking NSAIDs

● Tacrine (Cognex) for mild-moderate symptoms of Alzheimer’s ○ Associated with high frequency of side effects ■ GI effects ■ Elevated liver transaminase levels

■ Liver toxicity ○ **Withdrawn from US market in 2012 ● Donepezil (Aricept) ○ MOST commonly prescribed ○ For mild, moderate & severe Alzheimer’s ○ Improve cognitive functions without potential serious liver toxicity ○ Side effects: diarrhea & nausea (dose related) ● Rivastigmine (Exelon) [transdermal patch] ○ Side effects: nausea, vomiting, loss of appetite, and weight loss (most of time- temporary) ○ Should ALWAYS take with food...