Delirium, Dementia, and Amnestic Disorders Chapter 12 Delirium, Dementia, and Amnestic Disorders

Introduction Disorders in which a clinically significant deficit in cognition or memory exists

Introduction (cont.) The number of people with these disorders is growing because more people now survive into the high-risk period for dementia, which is middle age and beyond

Delirium Characterized by a disturbance of consciousness and a change in cognition that develop rapidly over a short period

Delirium (cont.) Symptoms Difficulty sustaining and shifting attention Extreme distractibility Disorganized thinking Speech that is rambling irrelevant, pressured, and incoherent

Delirium (cont.) Symptoms (cont.) Impaired reasoning ability and goal-directed behavior Disorientation to time and place Impairment of recent memory Misperceptions about the environment, including illusions and hallucinations

Delirium (cont.) Symptoms (cont.) Psychomotor activity that fluctuates between agitation, purposeless movements, and a vegetative state Emotional instability

Delirium (cont.) Symptoms include autonomic manifestations such as Tachycardia Sweating Flushed face Dilated pupils Elevated blood pressure

Delirium (cont.) Usually begins abruptly Can have a slower onset if underlying etiology is systemic illness or metabolic imbalance Duration is usually brief and delirium subsides completely on recovery from underlying determinant

Etiological Implications Delirium due to a general medical condition Substance-induced delirium Substance-intoxication delirium Substance-withdrawal delirium Delirium due to multiple etiologies

Dementia Defined as the loss of previous levels of cognitive, executive, and memory function in a state of full alertness

Dementia (cont.) Primary dementias are those in which the dementia itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer’s disease) Secondary dementias are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma)

Dementia (cont.) Symptoms Impairment exists in abstract thinking, judgment, and impulse control Conventional rules of social conduct are disregarded Personal appearance and hygiene are neglected

Dementia (cont.) Symptoms (cont.) Language may or may not be affected Personality change is common

Dementia (cont.) Reversible dementia is a function of the underlying pathological condition and of the availability and timely application of effective treatment In most individuals, dementia runs a progressive, irreversible course

Dementia (cont.) As the disease progresses, signs include Apraxia Irritability and moodiness, with sudden outbursts over trivial issues Inability to care for personal needs independently Wandering away from the home or care setting Aphasia Incontinence

Dementia (cont.) Alzheimer’s disease (AD) accounts for 50% to 60% of all cases of dementia Stages of Alzheimer’s disease Stage 1: no apparent symptoms Stage 2: forgetfulness Stage 3: mild cognitive decline

Dementia (cont.) Stages of Alzheimer’s disease (cont.) Stage 4: mild-to-moderate cognitive decline; confusion Stage 5: moderate cognitive decline; early dementia Stage 6: moderate-to-severe cognitive decline; middle dementia Stage 7: severe cognitive decline; late dementia

Etiological Implications Dementia of the Alzheimer’s type Onset is slow and insidious, and the course of the disorder is generally progressive and deteriorating Early onset (first symptoms at age 65 or before) Late onset (first symptoms after age 65)

Etiological Implications (cont.) Dementia of the Alzheimer’s type (cont.) Etiologies may include Acetylcholine alterations Plaques and tangles Head trauma Genetic factors

Etiological Implications (cont.) Vascular dementia The dementia is due to significant cerebrovascular disease There is a more abrupt onset than is seen in association with Alzheimer’s disease, and the course is more variable

Etiological Implications (cont.) Vascular dementia (cont.) Etiologies may include Arterial hypertension Cerebral emboli Cerebral thrombosis

Etiological Implications (cont.) Dementia due to HIV disease Results from brain infections caused by opportunistic organisms or the HIV-1 virus directly Symptoms may range from barely perceptible changes to acute delirium to profound dementia

Etiological Implications (cont.) Dementia due to head trauma Serious head trauma can result in symptoms associated with the syndrome of dementia Amnesia is the most common symptom Repeated head trauma can result in dementia pugilistica with symptoms of Dysarthria Ataxia Emotional lability Impulsivity

Etiological Implications (cont.) Dementia due to Lewy Body Disease Similar to Alzheimer’s Disease, but progresses more rapidly Lewy bodies (eosinophilic inclusion bodies) present in cerebral cortex and brainstem Progressive and irreversible May account for as many as 25% of all dementia cases

Etiological Implications (cont.) Dementia due to Parkinson’s disease Dementia is observed in as many as 60% of clients with Parkinson’s disease Cerebral changes in dementia due to Parkinson’s disease often resemble those of Alzheimer’s disease

Etiological Implications (cont.) Dementia due to Huntington’s disease Damage from this disease occurs in the areas of the basal ganglia and the cerebral cortex The client usually declines into a profound state of dementia and ataxia Average duration of the disease is based on age at onset

Etiological Implications (cont.) Dementia due to Pick’s disease Etiology of Pick’s disease is unknown but a genetic factor may be involved Clinical picture similar to that of Alzheimer’s disease Pathology results from atrophy in the frontal and temporal lobes of the brain

Etiological Implications (cont.) Dementia due to Creutzfeldt-Jakob disease Clinical symptoms typical of syndrome of dementia Symptoms also include involuntary movements, muscle rigidity, and ataxia Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid, with progressive deterioration and death within 1 year

Etiological Implications (cont.) Dementia due to Creutzfeldt-Jakob disease (cont.) Etiology is thought to be a transmissible agent known as a “slow virus” There is a genetic component in 5% to 15%

Etiological Implications (cont.) Dementia due to other medical conditions Endocrine conditions Pulmonary disease Hepatic or renal failure Cardiopulmonary insufficiency Fluid and electrolyte imbalances Nutritional deficiencies Frontal or temporal lobe lesions CNS or systemic infections Uncontrolled epilepsy Other neurological conditions (e.g., multiple sclerosis)

Etiological Implications (cont.) Substance-induced persisting dementia Dementia is related to the persisting effects of abuse of, or exposure to, substances such as Alcohol Inhalants Sedatives, hypnotics, and anxiolytics Medications (e.g., anticonvulsants, intrathecal methotrexate) Toxins (e.g., lead, mercury, carbon monoxide, organophosphate insecticides, industrial solvents)

Etiological Implications (cont.) Dementia due to Multiple Etiologies Diagnosis is used when the symptoms of dementia are attributed to more than one cause

Amnestic Disorders Amnestic disorders are characterized by an inability to Learn new information despite normal attention Recall previously learned information

Amnestic Disorders (cont.) Other symptoms may include Disorientation to place and time (rarely to self) Confabulation, the creation of imaginary events to fill in memory gaps

Amnestic Disorders (cont.) Other symptoms may include (cont.) Denial that a problem exists or acknowledgment that a problem exists, but with a lack of concern Apathy, lack of initiative, and emotional blandness

Amnestic Disorders (cont.) Onset may be acute or insidious, depending on underlying pathological process Duration and course may be variable and are correlated with extent and severity of the cause

Etiological Implications Amnestic disorder due to a general medical condition Head trauma Cerebrovascular disease Cerebral neoplastic disease Cerebral anoxia Herpes simplex encephalitis Poorly controlled insulin-dependent diabetes Surgical intervention to the brain

Etiological Implications (cont.) Transient amnestic syndromes can occur from Cerebrovascular disease Cardiac arrhythmias Migraine Thyroid disorders Epilepsy

Etiological Implications (cont.) Substance-induced persisting amnestic disorder Related to the persisting effects of abuse of, or exposure to, substances such as Alcohol Sedatives, hypnotics, and anxiolytics Medications (e.g., anticonvulsants, intrathecal methotrexate) Toxins (e.g., lead, mercury, carbon monoxide, organophosphate insecticides, industrial solvents)

Application of the Nursing Process: Assessment The client history: areas of concern to be addressed Type, frequency, and severity of mood swings Personality and behavioral changes Catastrophic emotional reactions Cognitive changes Language difficulties

Assessment (cont.) History: areas of concern to be addressed Orientation to person, place, time, and situation Appropriateness of social behavior Current and past use of medications, drugs, and alcohol Possible exposure to toxins Client and family history of specific illnesses

Assessment (cont.) Physical assessment Assessment for diseases of various organ systems that can induce confusion, loss of memory, and behavioral changes

Assessment (cont.) Physical assessment (cont.) Neurological examination to assess mental status, alertness, muscle strength, reflexes, sensory–perception, language skills, and coordination

Assessment (cont.) Physical assessment (cont.) Psychological tests to differentiate between dementia and pseudodementia (depression)

Assessment (cont.) Diagnostic laboratory evaluations Include blood and urine to test for Various infections Hepatic and renal dysfunctions Diabetes or hypoglycemia Electrolyte imbalances Metabolic and endocrine disorders Nutritional deficiencies Presence of toxic substances

Assessment (cont.) Other diagnostic evaluations may include Electroencephalogram (EEG) Computed tomography (CT) scan Positron emission tomography (PET) Magnetic resonance imaging (MRI) Lumbar puncture to examine cerebrospinal fluid (CSF)

Diagnosis/Outcome Identification Risk for trauma Disturbed thought processes Disturbed sensory-perception Risk for other-directed violence Impaired verbal communication

Diagnosis/Outcome Identification (cont.) Self-care deficit Situational low self-esteem Grieving

Outcomes The client Has not experienced physical injury Has not harmed self or others Has maintained reality orientation to the best of his or her capability Discusses positive aspects about self and life Fulfills activities of daily living (ADLs) with assistance Is able to communicate with consistent caregiver

Planning/Implementation Care plan for the client with a cognitive disorder is aimed at Protection of self and others Maintaining orientation to reality Minimizing confusion Fulfilling basic needs Assisting and educating prospective caregivers about appropriate care for their loved one

Client/Family Education Nature of the illness Possible causes What to expect Symptoms

Client/Family Education (cont.) Management of the illness Ways to ensure client safety How to maintain reality orientation Provide assistance with ADLs Nutritional information Difficult behaviors Medication administration Matters related to hygiene and toileting

Client/Family Education (cont.) Support services Financial assistance Legal assistance Caregiver support groups Respite care Home health care

Nursing Process: Evaluation Based on the accomplishment of outcome criteria

Medical Treatment Modalities Delirium Determination and correction of the underlying causes Staff to remain with client at all times to monitor behavior and provide reorientation and assurance

Medical Treatment Modalities (cont.) Delirium (cont.) Room with low stimulus level Low-dose neuroleptic agents to relieve agitation and aggression Benzodiazepines when etiology is substance withdrawal

Medical Treatment Modalities (cont.) Dementia Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes

Medical Treatment Modalities (cont.) Dementia (cont.) For cognitive impairment Physostigmine (Antilirium) Tacrine (Cognex) Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne) Memantine (Namenda)

Medical Treatment Modalities (cont.) Other pharmaceutical agents For agitation, aggression, hallucinations, thought disturbances, and wandering Risperidone (Risperdal) Olanzapine (Zyprexa) Quetiapine (Seroquel) Ziprasidone (Geodon) Haloperidol (Haldol)

Medical Treatment Modalities (cont.) Alert All antipsychotics carry a black-box warning stating that the drugs are associated with an increased risk of death in elderly patients with psychotic behaviors associated with dementia.

Medical Treatment Modalities (cont.) Other pharmaceutical agents (cont.) For depression Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Paroxetine (Paxil) Trazodone (Desyrel)

Medical Treatment Modalities (cont.) Other pharmaceutical agents (cont.) For anxiety (should not be used routinely for prolonged periods) Chlordiazepoxide (Librium) Alprazolam (Xanax) Lorazepam (Ativan) Oxazepam (Serax)

Medical Treatment Modalities (cont.) Other pharmaceutical agents (cont.) For sleep disturbances Flurazepam (Dalmane) Temazepam (Restoril) Triazolam (Halcion) Zolpidem (Ambien) Aleplon (Sonata) Eszopiclone (Lunesta) Ramelteon (Rozerem)