2. PATHO/DELIRIUM
• Cognitive Impairment
• If treat early enough is reversible
• Characterized by clouding of the
consciousness, inability to focus &
maintain attention, & altered
perception
3. DELIRUM
• Occurs in 10-40% of hospitalized clients,
30-40% of hospitalized client with AIDS,
& up to 60% of nursing home residents
who are 75 years old & older.
• 80% of hospitalized clients near death
will develop delirium.
• Occurs suddenly.
4. SYSTEM SPECIFIC
ASSESSMENT
• CNS(central nervous system) affected by
many conditions e.g. anemia, ischemia,
hypoglycemia, lack of Vitamin B, endocrine
disorders, toxicity from alcohol or drugs,
trauma, infections, etc.
• Physical restraints may contribute
5. SYSTEM SPECIFIC
ASSESSMENT
• Behavior: poor impulse control, may be
withdrawn or agitated
• Speech: dull or rapid & pressured
• Picking at clothing and/or the air
• Bizarre behavior at night/Sundowner’s
8. SYSTEM SPECIFIC
ASSESSMENT
• Cognition: disorganized thinking
(rambling speech) & ↓ ability to maintain
& shift attention
• Visual hallucinations /altered perception
are common
• Thinking, memory, attention and
perception are disturbed
10. INTERVENTIONS
• Eliminate cause of delirium
• Monitor LOC continually
• Reorient with each interaction – introduce self and
call client by their name
• Use short, simple, concrete phrases
• Keep the room well lit
• Provide clocks and calendars
• Have client use assistive devices (hearing
aids/glasses
• Clarify reality while justifying emotions/feelings
11. EVALUATE
PHARMOCOLGY
PHARMOCOLG
• Depends on cause of delirium
– Treat underlying cause first
• Haloperidol (Haldol) 1-2mg IV over
1-3 min may control symptoms.
May be given with lorazepam
(Ativan) IM
13. DEMENTIA
• Alzheimer disease (AD) is behind 60-70%
of late-onset dementias. Affects 4.8
million Americans
• $200 billion in U.S. spent yearly
• Affect 50% of persons over age 85
• Women more than men
• 15-20% are inherited
• Course is 5-10 years
14. CULTURE
• Cultural Influences:
• In U.S ↑ risk for AD in Latin Americans & African
Americans
• Japanese, Italians, & those from Hong Kong have
a greater risk in Europe & Asia
• ↑ lower educational and socioeconomic levels
• ↑clients with previous head injuries
• ↑ clients with relatives that have AD
15. ETIOLOGIES
• Video: www.nia.nih.gov/alzheimers/ADvideo
• Genetics – cause is unknown, focusing
on beta-amyloid protein that
accumulates into plaques
• Early onset (30 to 60 y/o) is rare (5%)
and is related directly to the Alzheimer’s
gene
16. ETIOLOGIES
• 1-Neurofibrillary tangles (twisted fibrils
inside the neuron that disrupt cellular
processes and eventually kill the cell)
• 2-Plaques (it is the quantity of plaques
in relation to the person’s age that is
significant) (a) widened sulci and
narrowed gyri
17.
18.
19. AD
• AD affects:
– Communication, metabolism, and repair
process of neurons in the brain
• Which causes:
– Memory failure
– Personality changes
– Difficulty carrying out ADLs
• There is a progressive decline
20. AD
•
•
•
•
• 4 stages
Mild – lasts 2-4 years
Moderate – longest stage, day care may
be necessary
Moderate to Severe AD – lasts 1-2 years,
24/7 care needed
Late/End stage
21. Stage 1 (Mild AD)
• Mild – lasts 2-4 years:
• characterized by
– Short-term memory loss
– Uses memory aids such as lists and
routine
– Aware of the problem
– Depression is common
– NOT diagnosable at this stage
22. Stage 2 (Moderate AD)
• Stage 2 Moderate AD is characterized by:
– Progressive memory loss
– Withdrawn from social activities
– Decline in instrumental ADLs (money
management, cooking, driving)
– DENIAL – fears “losing” his/her mind
– Depression
– Confabulation
– Symptoms worsen with physical/emotional stress
23. Stage 3 (Moderate/Severe AD)
• Stage 3 Moderate to Severe AD
is
characterized by:
– ADL losses: willingness to bathe, grooming,
choosing clothing, toileting, communication,
reading/writing
– Loss of reasoning ability
– Depression resolves as they become unaware of
loss
– Difficulty communicating
– Usually institutionalized or need care 24/7
24. Stage 4 (Late / End stage)
• Stage 4, late / end stage AD
is
characterized by:
– Family recognition/self recognition disappears
– Non-ambulatory
– Forgets how to eat, swallow, chew, wt loss
– Incontinent
– 24/7 care required
– Return to infantile reflexes and ultimately Death
• Death usually secondary to infection or choking
25. 7 WARNING SIGNS of AD
• Asking the same questions over & over
• Repeating the same story, word for
word, again & again
• Forgetting how to cook, or how to make
repairs, or how to play cards – activities
that were previously done with ease
• Losing one’s ability to pay bills or
balance one’s checkbook
26. 7 WARNING SIGNS of AD
• Getting lost in familiar surroundings
• Neglect to bathe, or wearing the same
clothes over & over while insisting
they are clean & are wearing dirty
clothes
• Relying on someone else close to
them to make decisions or answer
questions that they used to handle
28. EVALUATE
PHARMOCOLOGY
• DONAZEPIL (Aricept) 5mg P.O. daily @
bedtime. After 4-6 weeks↑ to 10mg
• Classification: cholinesterase inhibitor
• Action: improves cholinergic function by
inhibiting acetylcholinesterase
• Improves cognitive function
• *Missed doses should be skipped and
regular schedule returned to the following
day.
29. EVALUATE
PHARMACOLOGY
• Rivastigmine (Exelon) 1.5 mg. twice a
day with food, may ↑ by 1.5 mg. twice a
day every 2 weeks if tolerated. Target
dose 3 – 6 mg. twice a day. Max. dose
12 mg twice a day
• Classification: Cholinesterase Inhibitor
• Action: Treats mild to moderate AD
30. EVALUATE
PHARMACOLOGY
• Galntamine (Reminyl) 4 mg. twice a day
for at least 4 weeks, if tolerated may ↑
by 4 mg. twice a day every 4 weeks.
Target dose 12 mg twice a day.
• Classification: Cholinesterase inhibitor
• Action: treat mild to moderate dementia
31. EVALUATE
PHARMACOLOGY
SE: HA, diarrhea, nausea, sweating,
bradycardia, & insomnia
NSG: Taking after breakfast may
lessen side effects, teach how family
how to monitor pulse
*Do not cure – only slows down the
disease
32. EVALUATE
PHARMACOLOGY
• memantine HCL (NAMENDA)
• Used in moderate to severe Alzheimer’s
or with an acetylcholinesterase – less GI
disturbance
• Side effects: dizziness, HA, confusion
and constipation
34. ALTERNATIVE THERAPIES
• Antioxidants – found in green tea, grape seed
extract, deepest color fruits & veggies
• Omega-3 Fish Oil – found in salmon,
mackerel, sardines
• Phosphatidyl Serine – keeps nerve cells
flexible
• Melatonin – for sleep
• Estrogen – may be preventative in women
(not useful in existing dementia)
35. ALTERNATIVE THERAPIES
• Dehydroepiandrosterone (DHEA) –
regulates mood
• S_adenosylmethionine (SAMe) –
improves cell membrane flexibility,
caution in people with cardiac history
• Lecithin – found in soybeans & eggs
• Ginkgo Biloba –increase risk for
bleeding
36. ALTERNATIVE THERAPIES
• Music
– What type of music would be appropriate?
• Touch
– How should a client with dementia
touched? What approach should the nurse
take?
• Animal-Assisted
– Assess for fears first, if possible
37. SYSTEM SPECIFIC
ASSESSMENT
• Behavior: Wandering, unable to do complex
tasks, frightened by their confusion, attempt
to cover up symptoms, need assistance
dressing
• ↑ appetite & food intake – no ↑ in weight
• Repetitive behaviors – lip smacking, pacing
• Sundown Syndrome – disoriented at days’
end. Orientated in day.
38.
39. SYSTEM SPECIFIC
ASSESSMENT
• Affect:
• Mild stage: anxiety & depression occur
• Moderate stage: ↑ lability of emotions
(rage, irritability)
• Severe stage: person becomes
unresponsive to environment
40. SYSTEM SPECIFIC
ASSESSMENT
• Cognition: ↓ in concentration, ↑ distractibility,
absent-mindedness, unable to make
judgments
• Language skills begin to deteriorate
• Difficulty word-finding
• In mod AD – memory loss (recent & remote)
• Confabulation: filling in gaps with imaginary
information
41. SYSTEM SPECIFIC
ASSESSMENT - COGNITION
• Misidentification syndrome – familiar people
are unfamiliar
• Aphasia – unable to understand language
• Agraphia – unable to read or write
• Agnosia – unable to recognize familiar
people or situations
• Alexia – unable to tell what to do with a
frying pan, toothbrush, telephone
43. HIGHER NEEDS
• Can you think of some problems with
clients & AD as they try to fulfill their
higher needs? Which ones would be
affected?
– What would some interventions be to help
address these higher needs?
44. NURSING CARE
• Safety is first priority for delirium &
dementia
– What are some interventions we can do
address the safety issues for clients with
delirium and dementia?
• Find local resources such as _________
45. NURSING CARE
• What are some interventions that you
can think of for someone suffering from
AD?
• How would you assist families?
