Objective 9 2023 PDF

Objective #9: Cognitive Impairments & Associated Disorders Cognitive Function & Aging Disturbances in cognitive functioning. Cognitive Impairment Three D’s of CI : Delirium, Dementia, & Depression. Risk increases with older adults. Difficult to differentiate between the 3 D‘s. Cognitive assess...

Objective #9: Cognitive Impairments & Associated Disorders Cognitive Function & Aging Disturbances in cognitive functioning. Cognitive Impairment Three D’s of CI : Delirium, Dementia, & Depression. Risk increases with older adults. Difficult to differentiate between the 3 D‘s. Cognitive assessment is required. Delirium usually has a rapid onset, usually over hours or days. Dementia usually has a gradual onset and slow steady pattern of decline. Differentiating the 3 Ds Onset Consciousness Alertness Psychomotor activity Duration Attention Orientation Thinking Perception Affect Table 21-1 pg. 308 Delirium Distinguishing Features: DELIRIUM Risk Factors: DELIRIUM Infection Demographics – age and gender Hospitalization (change of environment) Medication (& taking multiple meds) Dehydration Restraints Losses Sensory impairment Pain Co-morbidities *May affect 50% of hospitalized older adults Dementia Screening / Treatment: DELIRIUM Confusion Assessment Method (CAM) • Thorough health assessment required including lab values • Imp. To determine cause Treatment & Approach • • • • • Calm, supportive approach Minimize stimuli Benzodiazepines / psychotropic meds (for alcohol withdrawal) Best management is non-pharmacological Box 21.4 Care Strategies for Delirium Prevention: DELIRIUM Dementia Irreversible state that slowly progresses over years, causes memory impairment, loss of intellectual functions severe enough to interfere with daily life. Apraxia - Inability to perform purposeful actions/ movements (sensory & motor abilities are intact). Agnosia - inability to recognize common objects & people, despite good vision or intact sensory abilities. Aphasia – loss of the ability to express & understand spoken & written language. Types: DEMENTIA Degenerative • • • • Alzheimer’s (50-70%) Parkinson’s Disease Dementia Lewy Body Dementia Frontotemporal Dementia Vascular Cognitive Impairment • Vascular Dementia • Mixed Dementia: Neurodegenerative and vascular • A group of disorders arising from cerebrovascular insufficiency or damage (poor circulation to brain) • *May result after a stroke, brain trauma, anoxia, and may be associated with diseases like diabetes, cardiac disease, resp. disease Primary, progressive dementia, unknown origin. Most common type. Alzheimer’s Disease Increasing memory loss, inability to concentrate, personality deterioration & impaired judgment. Course of disease 1- 20 years with life expectancy of 8-9 years after symptom onset Alzheimer’s Disease Parkinson’s Disease (PD) Parkinson’s Disease S/S • Resting Tremor (hands & feet) • Rigidity • Bradykinesia (slow movement) • Postural instability / abnormalities • Shuffling gait (festination – very short steps) Treatment • Treatment is focused on replacing dopamine, relieving symptoms, increased function, preventing excess disability & decreased risk of injury. • Medication used: Sinemet (levodopa) • Nonpharmacological interventions: exercise, relaxation, stress management, education, & self-care management • *Dopamine is a neurotransmitter that regulates movement in the body. Dementia: Responsive Behaviors Responsive Behaviors: are behaviors that result from the person misinterpreting their environment. They are collectively the Behavioral and Psychological Symptoms of Dementia (BPSD). Stressors that trigger BPSD: • • • • • • Physical stressors: Fatigue, hunger, illness, sleep deprivation. Change in - environment, routine, caregivers, restraints, misinterpreting environment. Stimuli - excessive or inappropriate. Performance demands: beyond abilities, pressured to do something not able, rushed care (AM care Physical discomfort e.g. pain Depression, loss of control, social isolation Pain & Dementia In Dementia, pain receptors in the brain change the way pain is perceived. ***Person still feels pain. S/S: increased periods of restlessness may indicate pain. Important for nurses assess & to learn an individual’s behavior that may indicate pain. Treat pain with medication as ordered. Dementia: GPA 1) Focused on the theme ‘I am not my disease’! & understanding the person behind the disease. This is a ‘Person-centered approach’ GPA: 4 Modules 2) Covers the progression of the disease, behavior of the person, & strategies to address behavior. 3) Focuses on building confidence in the caregiver to manage &, respond effectively to responsive behaviors. 4) Focuses on respectful, self-protection for the caregiver, also promoting safety for the person with dementia. Dementia: Sundown Syndrome Sundown Syndrome S/S Nursing Actions Becoming demanding or aggressive Provide a calm approach, minimize environmental stimuli, redirect, be consistent, avoid arguments. Experiencing delusions & hallucinations.. Pacing or wandering Doing impulsive things Attempting to leave home Having difficulty understanding others Having difficulty doing tasks that were done without difficulty earlier in the day Schedule actions that require more cooperation earlier in the day. Dementia Interventions for Wandering/Exiting Behaviors Call the person by name. Repeat to the person the concern that you hear. Face the person & use direct eye contact. Listen. Stay calm. Distract / redirect the person. Wandering patterns can be predicted through observation. (Box 21-11 pg 326) Interventions for Addressing Feeding Difficulties Reduce distractions. Medicate for pain prn. Arrange the tray to facilitate self-feeding. Serve one food at a time. Serve finger foods if the person can not manage utensils. Remove hot items until they cool. Use verbal cueing with simple instructions. Strategies to Assist with ADLs Know the person’s lifetime bathing routines and preferences. Provide care only when the person is receptive. Respect refusals to participate in care; explain all actions. Realize that a bath is not an essential intervention. Encourage self-care to the extent possible; make bathrooms and shower areas warm, comfortable, and safe. Be attentive to pain and discomfort; use alternative bathing methods such as a towel bath or sponge bath Management of Dementia: NONPHARMACOLOGICAL APPROACHES Reality / Orientation Therapy Validation Therapy Touch Therapy Recreation Therapy Music Therapy Socialization Non-pharmacological Management Reality/Orientation Therapy • Based on premise that if the person is orientated to person, place & environment the BPSD (responsive behaviors) will be less. This may have to be done frequently. • Example: The nurse should provide their name, verbalize the place where they are, & reinforce what is going on in the moment. Validation Therapy • The care giver validates the feelings expressed by the person with dementia. This is thought to reduce irritability. Example: ‘I see you are upset…’ Non-Pharmacological Management Touch Therapy • Touch and other forms of reassurance may help the person refocus on a different thoughts and set of feelings. Person may feel supported and understood. Caution - assess appropriateness for use. Socialization • Engage persons with dementia in meaningful social interactions, enhances their quality of life and provides a positive distraction. NonPharmacological Management Music Therapy • Research supports that participation in music therapy is effective in reducing disruptive behavior during and immediately after the therapy. Recreation / Exercise • Participation in meaningful activities, that are simple but stimulating, can reduce boredom & may decrease responsive behaviors. • Encouraging walking in a safe area or doing simple ‘easy to follow’ exercises may decrease wandering behavior. Exercise can improve physical, cognitive & functional abilities. Pharmacological Approaches * Avoid overuse of calming medications for agitation, it is reserved for extreme responsive behaviors * Use least restrictive methods if possible Depression Depression Risk Factors • • • • • • • Dementia Bereaved Caregiving History of depression Medications Living alone / widowed Multiple losses that are exhausting coping abilities • *Assess for suicide risk S/S • 1. Decreased energy & motivation • 2. Frequent complaints (somatic) • 3. Altered appetite ( increase or decrease) • 4. Decrease in ability to concentrate • 5. Perceived cognitive deficits • 6. Critical or envious of others • 7. Loss of self-esteem • 8. ‘Model’ patient Increased disability Depression: Negative Outcomes Delayed recovery from illness Excessive use of health services Cognitive impairment Malnutrition Decreased quality of life Suicide & non-suicidal related deaths Depression: Treatment Psychological focused: • Counseling, reminiscence groups, grief counseling, enhance support, education (family). Pharmacological: • Antidepressants. Cognitive Impairment: Effective Communication Older adults may need more time to respond – Be patient. Pay attention to non-verbal cues. Watch your own non-verbal communication. Communicate at the level of patient / resident (where possible). *Remember Behaviour has meaning Mental Capacity Mental Capacity Role of LPN Know cognitive disorders, S/S & illness trajectory. Understand issues / protocol around wandering, confusion & related behaviors. Use effective communication techniques & approaches to care. Know legalities around mental capacity, consents, restraints, safety measures. Use Nursing Process. • *Assessment, Planning, Implementation & Evaluation* Documentation of behaviors, responses to interventions, triggers to behavior changes, change in condition. Individualize care. Know agency policies.