Delirium, Dementias, and Related Disorders

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Delirium, Dementias, and Related Disorders

• Chapter 29

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Key Concepts

• Cognition
• System of interrelated abilities, such as
  perception, reasoning, judgment, intuition and
  memory
• Allows one to be aware of oneself
• Memory
• Facet of cognition, retaining and recalling past
  experiences
• Delirium
• Acute cognitive impairment caused by medical
  condition
• Dementia
• Chronic, cognitive impairment
• Differentiated by cause, not symptoms

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DeliriumClinical Course

• Disturbance in consciousness and a change in
  cognition
• Develops over a short period of time
• Usually reversible if underlying cause identified
• Serious, should be treated as an emergency

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DeliriumDiagnostic Criteria

• Impairment in consciousness - key diagnostic
  criteria
• Children - can be related to medications or fever
• Elderly - most common in this group, often
  mistaken as dementia

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DeliriumEpidemiology Risk Factors

• Prevalence rates from 10-30 of patients
• In nursing homes, prevalence reaching 60 of
  those older than the age of 75 years
• Occurs in 30 of hospitalized cancer patients
• 30-40 of those hospitalized with AIDS
• Higher for women than men
• Common in elderly, post-surgical patients

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DeliriumEtiology

• Complex and usually multidimensional
• Most commonly identified causes
• Medications
• Infections
• Fluid and electrolyte imbalances
• Variety of brain alterations

• Imbalance of neurotransmitter
• Raised plasma cortisol level
• Involvement of white matter

• Reduction in cerebral functioning
• Damage of enzyme systems, blood brain barrier or
  cell membranes
• Reduced brain metabolism

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Types

• Due to General Medical Condition
• Substance-Induced
• Substance-Intoxication
• Substance-Withdrawal
• Multiple Etiologies

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Medications

• Anticholinergic
• Antihistamines, Chlorpheniramine, Ornade
  Teldrin), antiparkinsonian drugs (Cogentin,
  Akineton, atropine, diphenhydramine,
  phenothiazines, promethazine (Phenergan),
  scopolamine, TCA
• Anticonvulsant
• Phenobarbital, phenyton (Dilantin), sodium
  valproate (Depakene)

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Medications

• Anti-inflammatory
• Corticosteroids, ibuprofen, indomethacin
  (Indocin), naproxen (Naprosyn)
• Antiparkinsonian
• Amantadine (Symmetrel), carbidopa (Sinemet)
• Antituberculous
• Levodopa (Larodopa), isoniazid, rifampin

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Medications

• Analgesic
• Opiates, salicylates, synthetic narcotics
• Cardiac
• Beta blockers, propranolol (Inderal), clonidine
  (Catapres), digitalis (Digoxin, and Lanoxin),
  lidocaine (Xylocaine), methyldopa (Aldomet),
  quinidine, procainamide (Pronestyl)

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Medications

• Sedative/Hypnotic
• Barbiturates, benzodiazepines
• Sympathomimetic
• Amphetamines, phenylephrine, phenylpropanolamine
• OTC
• Compoz, Excedrin PM, Sleep-Eze, Sominex

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Medications

• Miscellaneous
• Antiviral, aminophylline, amphotericin
  (antifungal), bromides, cephalexin (Keflex),
  chlorpropamide (Diabinese), cimetidine (Tagamet),
  disulfram (Antabuse), lithium, metronidazole
  (Flagyl), theophylline, timolol opthalamic

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Physiological

• Fluid/kidney
• Dehydration, Hypocalcemia, Hypokalemia, Abnormal
  sodium, Low serum albumin, Elevated BUN, Elevated
  creatinine, Azotemia, Proteinuria, CRD
• Cardiac/Respiratory
• Hypotension, CVD, CHF, AA, Elevated PT, Low
  hematocrit, Respiratory insufficiency, Noncardiac
  thoracic surgery

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LABS

• BUN
• 7-18mg/dL or 2.5-6.4 mmol/L
• gt60 8-20 mg/dgt or 2.9-7.5 mmol/L
• Creatinine Clearance
• Men 94-140 mL/min/1.72
• Women 72-110mL/min/1.73m
• Serum Albumin
• Normal 3.5-5.0g/dL

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Labs

• Hyponatremia
• lt12mEq/L
• Hypocalcemia
• lt4.65-5.28mg/dL
• Hypokalemia
• lt2.8mEq/L
• Elevated PT
• Critical Value gt30 seconds.

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Physiological

• Metabolism/Temperature
• Metabolic disturbances, Nutritional deficiencies,
  Abnormal Glucose,
• Normal Fasting Adults lt-110 mg/dL
• Elevated AST/SGOT
• Normal 8-20 U/L
• Abnormal Temperature
• Age, gender
• Age 65 and older (higher incidence over 80)
• Male
• Limited social contact, Admission from an
  institution

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Physiological

• Infection and Trauma
• Symptomatic infection
• Urinary tract infection
• Respiratory infection
• Elevated WBC
• Emergency Admission
• Fracture
• Falls
• Orthopedic surgery
• Combination illnesses

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Physiological

• More than 4 medications
• Drugs with anticholinergic or CNS effects
• Hypoxia/Ischemia

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Interdisciplinary Treatment Priorities

• Interdisciplinary treatment
• Elimination or correction of the underlying cause
• Symptomatic and supportive measures
• Priorities
• Safety
• Pay attention to life-threatening disorders.
• Rule out life-threatening illness.
• Stop all suspected medications.
• Monitor vital signs.

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Nursing Management Biologic Domain Assessment

• Identify normal
• Past and present health status
• Description of onset, duration, range and
  intensity of symptoms
• Presence of chronic physical illness, dementia,
  depression, etc.
• Physical exam and review of symptoms
• Special attention to lab values CBC, BUN,
  creatinine, electrolytes, liver function and O2
  saturation
• Physical functions - ADLs, activity level, pain

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Nursing ManagementBiologic DomainPharmacologic
Assessment

• Substance abuse history
• Assess for combinations of medications
• OTC medication

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Delirium Biologic DomainNursing Diagnosis

• Acute confusion
• Disturbed thought processes
• Disturbed sensory perception
• Hyperthermia
• Acute pain
• Risk for infection
• Disturbed sleep pattern

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DeliriumBiologic Nursing Interventions

• Safety
• Protection from physical harm
• Low beds, guard rails and careful supervision
• Maintaining fluid and electrolyte balance
• Adequate nutrition
• Prevent aspiration
• Prevent decubitus ulcers
• Pharmacologic
• Treatment of the behavior must consider potential
  anticholinergic side effects.
• Lowest possible dose

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DeliriumPsychological DomainAssessment

• Cognitive changes with rapid onset (several
  scales see page 678)
• Fluctuations in level of consciousness, reduced
  awareness of environment
• Difficulty focusing, sustaining or shifting
  attention
• Severely impaired memory
• May be disoriented to time and place, but rarely
  to person
• Environmental perceptions altered
• Illogical thought content
• Behavior change
• Hyperkinetic delirium psychomotor hyperactivity,
  excitability, hallucinations
• Hypokinetic delirium lethargic, somnolent,
  apathetic

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Delirium Psychologic DomainNursing Diagnosis

• Acute confusion
• Disturbed thought process
• Ineffective coping
• Disturbed personal identity

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DeliriumPsychological Nursing Interventions

• Frequent interaction
• Support for confusion or hallucinations
• Encouraged to express fears and discomforts
• Adequate lighting
• Easy-to-read calendars and clocks
• Reasonable noise level
• Frequent verbal orientation
• Devices available - eye glasses and hearing aids

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Delirium Social DomainAssessment

• Assessment of living arrangement
• Cultural and educational background considered
• Presence of family support
• Family interactions

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Delirium Social DomainNursing Diagnosis

• Interrupted family processes
• Ineffective protection
• Ineffective role performance
• Risk for injury

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DeliriumSocial Nursing Interventions

• Safe environment
• Predictable, orienting environment
• Avoid physical restraint
• Presence of family members can be helpful

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Evaluation

• Correction of underlying physiologic alteration
• Resolution of confusion
• Family member verbalization of understanding
• Prevention of injury

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Delirium Dementia

• Sudden onset
• Fluctuating course
• ? consciousness
• ? attention
• ? cognition
• Hallucinations
• ? activity
• Incoherent speech
• Involuntary motor movement
• Illness, toxicity

• Insidious onset
• Stable course
• Clear
• Clear
• ? cognition
• May be present
• Normal
• Normal
• Normal
• Normal

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Dementia Alzheimers Type

• Degenerative, progressive neuropsychiatric
  disorder that results in cognitive impairment,
  emotional and behavioral changes, physical and
  functional decline, and ultimately death
• Types
• Early-onset (65 years and younger)
• Rapid progression
• Late-onset (over 65)
• Stages mild, moderate, severe (Figure 29-1)

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Dementia/Alzheimers Progression
Stage Mild Moderate Severe Mild Moderate Severe Mild Moderate Severe
SYMPTOMS Loss of memory Inability to retain new info Gait and motor disturbances
Language difficulties Personality changes Bedridden
Mood swings Inc. LT memory loss Unable to perform ADL
Personality changes Wandering, agitation Incontinence
Diminished judgment confusion
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Diagnosis of AD

• Essential feature - multiple cognitive deficits
• One or more of the following
• Aphasia (alterations in language)
• Apraxia (impaired ability to execute movement)
• Agnosia (failure to recognize or identify
  objects)
• Disturbance of executive functioning

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Epidemiology

• 4 millions Americans
• 6 million by the year 2040
• 10 over 65 years, 47.2 over 85 ears
• Highest prevalence over the age of 85
• Twice as common in women

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Risk Factors

• Age
• Gender
• Can run in families
• Low educational levels (for women)

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Etiology

• Neuritic plaques (extracellular lesions) Highest
  density in temporal and occipital lobes,
  intermediate in parietal lobes, lowest in frontal
  and limbic cortex
• ?-amyloid protein
• Apolipoprotein A cores
• Neurofibrillary tangles initially in limbic
  then progress to cortex
• Apolipoproprotein E
• Cholinergic hypothesis
• Acetylcholine is associated with cognitive
  function/disruption damages memory
• ACh is reduced
• Lowered Norepinephrine loss of cells in locus
  ceruleus
• Lowered Serotonin neuronal loss in raphe nuclei
• Genetic factors
• Roles of chromosome 1, 14 and 21
• Oxidative stress and free radicals
• Inflammation

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Interdisciplinary Treatment

• Confirmation of the diagnosis
• Establishment of baseline levels in functional
  sphere
• Establishment of a therapeutic relationship with
  patient and family
• Management of cognitive symptoms
• Delaying cognitive decline
• Treatment of non-cognitive symptoms - psychosis,
  mood symptoms and agitation
• Support caregivers

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Priority Care Issues

• Priorities will change throughout the course of
  the disorder.
• Initially, delay cognitive decline.
• Later, protect patient from hurting self.
• Later, physical needs become the focus of care.

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Family Response to AD

• Family can be devastated.
• Caregivers health and well-being are often
  compromised.
• Caregiver distress is a major risk factor.
• Caregiver burden often leads to nursing home
  placement.
• Caregiver support can delay nursing home
  placement.

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Nursing ManagementBiologic DomainAssessment

• Past and present health status (compare to
  typical)
• Physical examination and review of systems
• Vital signs, neurologic status, nutritional
  status, bladder and bowel function, hygiene, skin
  integrity, rest and activity, sleep patterns, and
  fluid and electrolyte balance
• Physical functions
• Self-care
• Sleep-wake disturbances
• Activity and exercise
• Nutrition
• Pain

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Dementia Biologic DomainNursing Diagnosis

• Imbalanced nutrition
• Self-care deficits (feeding, bathing/hygiene,
  toileting, constipation)
• Impaired swallowing
• Bowel incontinence
• Impaired urinary elimination
• Functional incontinence
• Deficient fluid volume

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DementiaBiologic Nursing Interventions

• Self-care
• Maintaining independence as much as possible
• Oral hygiene
• Nutritional
• Monitoring patients weight, oral intake and
  hydration
• Well-balanced meals
• Observation for swallowing difficulties
• Sleep interventions
• Activity and exercise - Balance activity with
  sleep.
• Pain and comfort management - Assess carefully,
  and do not rely on verbalizing pain.
• Relaxation

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Pharmacologic Interventions

• Acetylcholinesterase inhibitors (AChEI)
• Donepezil (Cognex)
• Rivastigmine (Exelon)
• Galantamine (Reminyl)
• Used to delay cognitive decline
• Most common side effects nausea, vomiting
• Antiinflammatory - Ibuprofen
• Antipsychotics
• Antidepressants and mood stabilizers
• Antianxiety medications - used with caution
• Avoid medications with anticholinergic side
  effects.

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DementiaPsychological DomainAssessment

• Responses to mental health problems - personality
  changes
• Cognitive status (MMSE and others)
• memory visuospatial
• language executive functioning
• Psychotic symptoms
• suspiciousness, delusions and illusions
• hallucinations

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DementiaPsychological DomainAssessment (cont.)

• Mood changes
• Depression
• Anxiety
• Catastrophic reactions
• Behavioral responses
• Apathy and withdrawal
• Restlessness, agitation and aggression
• Aberrant motor behavior
• Disinhibition
• Hypersexuality
• Stress and coping skills

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Dementia Psychological DomainNursing Diagnosis

• Impaired memory
• Disturbed thought processes
• Chronic confusion
• Disturbed sensory perception
• Impaired environmental interpretation syndrome
• Risk for violence
• Risk for loneliness
• Risk for caregiver role strain
• Ineffective individual coping
• Hopelessness
• Powerlessness

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DementiaPsychological Nursing Interventions

• Therapeutic relationship
• Interventions for cognitive impairment
• Validation therapy
• Memory enhancement
• Orientation
• Maintenance of language functions
• Supporting visuospatial functioning
• Interventions for psychosis
• Management of suspicious, illusions, delusions
• Management of hallucinations

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DementiaPsychological Nursing Interventions

• Interventions for alterations in mood
• Management of depression (Do not force
  activities, but encourage them.)
• Management of anxiety by helping patient deal
  with stress
• Remaining calm during catastrophic reactions,
  minimizing environment distractions, speaking
  slowly, being reassuring

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DementiaPsychological Nursing Interventions

• Interventions for behavior problems
• Keep close contact with family help engage
  patient.
• Do not interrupt wandering behavior, but identify
  pattern. Determine if he/she is confused and can
  not find way walk with patient, then re-direct.
• Distract for picking in air, wringing hands.
• Determine meaning of vocalizations.
• Determine antecedents to agitated behavior.
• Reduce stimulation to minimize disinhibition.

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DementiaSocial DomainAssessment Nursing
Diagnosis

• Assessment
• Functional status, social systems, spiritual
  assessment, legal status and quality of life
• Extent of primary caregivers personal, informal
  and formal support systems
• Nursing Diagnoses
• Deficient diversional activity
• Impaired social interaction
• Social isolation
• Caregiver role strain

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Dementia Social Nursing Interventions

• Patient safety interventions adjusted for
  progression through stages of dementia
• Environmental interventions
• Socialization activities
• Home visits

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Family Interventions

• Provide support, support, support.
• Make home visits.
• Encourage caregivers to attend support groups.
• Inform family of available day care centers, home
  health agencies and other community services.

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Other Dementias

• Vascular dementia
• Dementia caused by other conditions
• AIDS
• Parkinsons
• Huntingtons
• Picks
• Creutzfeldt-Jakob Disease
• Substance-induced

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Amnestic Disorder

• Impairment in memory caused by medical condition
  or persisting effects of a substance
• Severe memory impairment without other
  significant cognitive symptoms
• Can be caused by a variety of pathologic processes