Trisha Economidis Marilee Elias Fall 2010 Dementia & Delirium Eating Disorders Disorders Common in Children & Adolescents Personality Disorders Trisha Economidis Marilee Elias Fall 2010

Dementia & Delirium Common problems of the Elderly Patient What do we observe? How does it develop? What are the symptoms? What are the etiologies? What are the interventions?

Delirium Characterized by “disturbance of consciousness and a change in cognition” (APA) Temporary State of Confusion Develops rapidly Symptoms Cognition Level of Consciousness Psychomotor Activity Emotions

Delirium Etiologies: General Medical Conditions Substance-Induced Substance-Intoxication and/or Withdrawal Multiple Etiologies

Delirium Interventions This is an Emergency Aggressive Treatment Safe Environment Sensory Perceptions Reorient & reorient & reorient

Dementia Not a normal part of Aging Loss of previous levels of cognitive, executive & memory function Usually Progressive & Irreversible Classifications Primary Dementias Secondary Dementias Temporary Dementia

The Many Stages of DAT Stage 1: No apparent symptoms Stage 2: Forgetfulness Stage 3: Mild cognitive decline Stage 4: Mild-moderate cognitive decline, Confusion Stage 5: Moderate cognitive decline, Early Dementia Stage 6: Mod-severe cognitive decline, Middle Dementia Stage 7: Severe cognitive decline, Late Dementia

Interventions with Dementia Orient to reality Clocks, calendars Promote memory/reminiscing Familiar items, Pictures, Music Provide safe, structured environment

Eating Disorders Anorexia Nervosa Bulimia Nervosa

Anorexia Nervosa Who presents with this disorder? What do they fear? What’s distorted? What does the patient do about food? Exercise? What about self-worth? Physical Symptoms?

Self-worth & Physical Symptoms The self-worth’s connected to the symptoms.. What’s up with weight? What’s happening with muscles? Is it cold in here? What happens to the cardiac system? Yellow skin, lanugo

Bulimia Nervosa What’s Bulimia? What’s binging? What’s purging? What are the physical symptoms? Weight Dentition Check out those hands Cardiac concerns Electrolyte imbalances

Etiologies for Anorexia/Bulimia Is it in the genes? Neuroendocrine abnormalities The factors of family dysfunction What’s up with your parents?

Personality Disorders What are they? What are their characteristics? Often co-exist with? Three clusters of behavior A= Odd, eccentric B= Dramatic, emotional, or erratic C= Fearful, Anxious

Personality Disorders Cluster A Paranoid, Schizoid Cluster B Antisocial Borderline Narcisisstic Cluster C Passive-aggressive

Paranoid Personality Disorder Cluster A Men> Women Early adult onset Who do they suspect and mistrust? Hypervigilant and READY for ALL threats Why do they seek treatment?

Schizoid Personality Disorder Cluster A Men diagnosed> Women Pattern of social withdrawal They are way too serious Spontaneity? Inability to form personal relationships Prevalence in general population?

Antisocial Personality Disorder Cluster B Men 3X> Women Exploitative, aggressive & manipulative Lacks a lot Where do we find them? Lower SEC > Higher SEC

Borderline Personality Disorder Cluster B Emotionally unstable, intense, impulsive, self-destructive The most common personality disorder Women up to 4X > Men What’s splitting got to do with it? It’s all or nothing

Narcissistic Personality Disorder Cluster B Inalienable right to special rights & privileges Too much self-worth Men> Women Exploitive Overly self-centered

Passive/Aggressive Personality Disorder Cluster C Onset by early adulthood Envy and resent others Negative attitudes Passive resistance to social, work situations Procrastinate, or “forget” to resist Crave attention, reassurance Covertly vent anger and resentment

Disorders Common in Children and Adolescents Mental Retardation Autistic Disorder Attention-deficit/Hyperactive Disorder Conduct Disorder Oppositional Defiant Disorder Tourette’s Syndrome Separation Anxiety Disorder

Emotional Problems in Children Behaviors are: Not age appropriate Deviate from cultural norms Cause deficits or impairments in adaptive functioning

Mental Retardation Etiology? Those genes again! Prenatal factors Pregnancy and perinatal factors General medical conditions in infancy or childhood Environmental influences and other mental disorders

Mental Retardation IQ Tests What is the DSM-IV-TR criteria? Measure deficits in general intellectual functioning What is the DSM-IV-TR criteria? Additional impairments or deficits: Communication, self-care, self-direction, functional academic skills, work, health, safety and more Adaptive functioning Able to adapt to daily living requirements? Meet expectations of person’s age or cultural group?

Mental Retardation Characteristics by Degree of Severity Mild Moderate Severe Profound Townsend, table 22-1, p. 527

What are the Interventions? Individualized Plan The 3-Rs Provide safe, comfortable environment Positive reinforcements Let’s do things in a simple, concrete way It’s always a “family” affair

Down’s Syndrome Most common chromosomal disorder with developmental delays Prevalence 1/800 live births in the US ↑ Incidence in women > 35 years old Extra chromosome at #21 = total of 47 Causes changes in both body and brain Mild to moderate mental retardation

What do we find with Down’s Syndrome? Mental retardation with developmental delays of varying degrees Physical characteristics? Head, face, neck Muscles Hands Abdomen Genitalia

Pervasive Developmental Disorders What are the characteristics? Impaired areas of development Social Interaction Skills Interpersonal Communication This Category includes: Autistic Disorder Asperger’s Disorder

Autistic Disorder Prevalence 1/150 children in the US Boys 4-5 X> girls Onset before 3 years of age Etiologies include: Neurological Genes again Perinatal Influences

Symptoms of Autism Impaired social interactions Impaired communication Impaired imagination Rigid routines Activities and Interests Impaired Diet

Asperger’s Disorder High functioning autism Later onset of symptoms No significant delays in language, cognitive development, self-help skills Severe, sustained social interaction impairment Problems with empathy

ADHD Etiologies Genes (again?) Biochemical Anatomical Neurotransmitters Anatomical Alterations in the brain Prenatal, perinatal, postnatal factors Environmental factors Psychosocial factors

ADHD Interventions Provide a safe environment Positive feedback Develop trusting relationship with caregivers Help child interact with others at an appropriate level of maturity

Psychopharmacological Interventions for ADHD Stimulants? Why? Paradoxical effects of CNS stimulants ↓ Hyperactivity ↑ Ability to focus, learn and work What drugs? What can we do to address side effects?

Disruptive Behavior Disorders Severe enough to produce significant impairment: Social Academic Occupational Conduct Disorder Oppositional Defiant Disorder

Conduct Disorder What is the pattern of behavior? What’s violated? What’s common? DSM-IV-TR Subtypes Childhood Onset Usually boys, physical aggression Adolescent Onset Lower ratio boys to girls, physical aggression less likely

Does Conduct Disorder progress? Childhood onset subtype Possible ODD early Conduct disorder by puberty Antisocial personality disorder as Adults

Conduct Disorder Etiologies Genes (again and again) Difficult Temperament Biochemical Diagnosis of ADHD Psychosocial Factors Family Dynamics Peer Relationships

Nursing Interventions Managing Aggressive Behavior Protecting others from Physical Aggression Improving interactions with others Developing age-appropriate, acceptable behaviors Client accepting responsibility for own behavior

ODD Oppositional Defiant Disorder What’s the pattern of behavior? Who is the behavior directed against? Impaired functioning: Social, academic and/or occupational Onset by 8 years of age Pre-puberty Boys> Girls Puberty more equal Male/Female ratios

ODD Etiologies Biological influences Family Influences Possibly Genetic Family Influences Parental Problems A power struggle

Symptoms of ODD Passive-Aggressive Behaviors What will the child do? Other Physical Manifestations? Enuresis Encopresis

Nursing Interventions for ODD ↑ Compliance with Therapy Developing less negative attitude Client accepts responsibility for behaviors ↑ Self-esteem Client verbalizes positive self-statements Improved interactions with staff and peers

Tourette’s Syndrome Essential Features? Onset Etiologies Structural Before 18 years of age Boys > Girls Etiologies Guess what’s first on the list Biochemical Structural Areas of Brain Dysfunction Environmental

Treatment of Tourette’s Syndrome Psychosocial Therapy Includes the Family Psychopharmacological Therapy Drugs Haloperidol (for Severe Symptoms) Pimozidine (Severe Symptoms after other drug failures) Clonidine (Safe, Few Side Effects) Atypical Antipsychotics Risperidone (Good reduction of symptoms) Ziprasidone Olanzopine

Separation Anxiety Disorder What’s the essential feature? (think excess) Onset Anytime before 18 years of age As early as preschool age Girls > Boys

Separation Anxiety Etiologies You already know the first one Temperament Environmental Influences Family Influences Stressful Life Events

Separation Anxiety Symptoms Difficult separations from who? Anticipation of separations Refusing to… Specific Phobias Depressed Mood

Nursing Interventions Provide safe, secure environment Assist your client to: Reach manageable level of anxiety Develop adequate coping strategies Spend time away from attachment figure Interact with others

What treatment modalities do we use for Children and Adolescents? Behavior Therapy Family Therapy Group Therapy What kinds? Psychopharmacology Not used as the sole method of treatment

Brains Full Yet?