Adult Health Delirium, Dementia, Alzheimer’s and Parkinson’s

Delirium
acute, fluctuating change in mental status

sudden, acute onset

temporary; may last hours or days

worsens at night

fluctuates; fine during day, confused at night

disorganized, distorted, impaired attention/memory

hallucinations

caused by changed in hemodynamic status

description: acute state of confusion

onset: acute, happen within hours/minutes/days (comes suddenly and leaves suddenly)

duration: 3 weeks up to a month

cause: hemodynamic instability

reversibility: yes

management: treat the cause

nursing interventions: reorient person, find cause; treat cause; nurse can test using confusion assessment method (CAM)

Signs and Symptoms of Delirium
Sudden, acute, fluctuating change in mental status
– comes on quickly and leaves quickly

Temporary mental status changes-may last for hours or days

Worsens at night

Alertness fluctuates

Disorganized and disordered thinking
– count backwards from 20; can do it but if you tap on book while trying, they can’t count backwards

Impaired attention

Altered memory

Visual, auditory and perceptual hallucinations
– see spiders on bed; think you are someone else; hear things that aren’t there

Misinterpretations of real sensory experiences
– tapping on book might think that is someone breaking in or using a jackhammer

Precipitating Factors of Delirium
Infection-especially UTI in elderly

Acute renal failure

Medications

Acute hepatic failure
– can’t clear drug like everyone else

Hypoxia, Hypercapnia

Dysrhythmias

Hypo/Hypervolemia
– dehydration and over-hydration

Fecal impaction

Electrolyte Imbalance
– sodium

Substance withdrawal
– alcohol

Acidosis/Alkalosis
– DKA

Congestive heart failure
– decreased O2; fluids; electrolytes

Hypo/Hyperglycemia

Hypo/Hyperthermia

Impact of Delirium on Patient
DEATH
Nursing Interventions for Delirium
Obtain baseline **LOC upon admission, handoff report and when talking with family.
– AAOx3; know where they are; who they are; who you are; what is baseline

Monitor patient’s LOC every four hours

Monitor patients VS and lab values throughout your shift.

If you notice a change in LOC, identify possible precipitating factors and call physician.
– talk to family too

Attempt to reorientate the patient often.
– its April, what day it is; where you are; time of day; what year; what month

Differentiate between delirium and dementia

Treat the cause of the hemodynamic instability.

DO NOT SEDATE A PATIENT WITH SUSPECTED DELIRIUM.

DOC-Haldol (antipsychotic) IV/IM/PO
– Only given in hyperactive states of delirium
– Side effects: tardive dyskinesia, orthostatic hypotension, respiratory depression
– Dementia-Black Box Warning-risk for death

Dementia
description: chronic/progressive state of cognitive loss

onset: slow onset

duration: long til death

cause: unknown

reversibility: no

management: medications; surgery type procedures

nursing interventions: reorient person; find cause; treat cause; look at symptoms; provide safe environment

memory impairment

slow, insidious

chronic, gradual, irreversible

no change with time of day

alertness generally normal

judgement impaired

delusions

caused by Alzheimer’s/Infarct

Chronic confusion with symptoms that are gradual and irreversible

Example: Alzheimer’s

Pathophysiology of Alzheimer’s
A patient with Alzheimer’s exhibits microscopic changes, vascular degeneration and reduced neurotransmitters. (confirmed by autopsy) neurofibrillary tangles and neuritic plaques

Exact cause is unknown.

Risks for Developing Alzheimer’s
Environmental Risks
– Those who have experienced head injury, repeated head trauma exposure to toxic environmental agents and metals, herpes zoster and simplex

Genetic Risks
– Age, gender (women more than men), and family history of AD or Down’s Syndrome, race (Blacks higher than whites)

Alzheimer’s Terms
Cognition- ability of the brain to store, process, retrieve and use information

MMSE-Mini Mental State Examination

Apraxia-inability to use words or objects correctly

Aphasia-inability to speak

Anomia-inability to find words

Agnosia-loss of sensory perception

Sundowning-increased confusion at night or when light is not adequate

Prosopagnosia-loss of recognition of oneself or others

Stages of Alzheimer’s Disease

Early (Mild) or Stage 1

first symptoms up to four years

Independent in ADLs

unable to travel alone

No social or employment problems initially

decreased sense of smell
– peanut butter test

Denies presence of symptoms

Forgets names, misplaces household items

Short term memory loss -one of the first symptoms

Subtle changes in personality and behavior

Loss of initiative

Mild cognitive impairment, judgment

**Ideal stage to start medication- Aricept, Namenda

Stages of Alzheimer’s Disease

Middle (Moderate) or Stage II

2-3 years

Impairment of all cognitive functions

Unable to handle money and finances

Disorientation to time place and event

Possible depression, agitated

Increasingly dependent in ADLs

Difficulty driving, gets lost

Speech and language deficits

Wandering, trouble sleeping

Stages of Alzheimer’s Disease

Late (Severe) or Stage III

Completely incapacitated, bedridden

Totally dependent in ADLs

Motor and verbal skills lost

General and focal neurological deficits

Agnosia (loss of sensory perception)

Prosopagnosia (inability to recognize oneself or others)

Nursing Interventions-Alzheimer’s
Goal: Keep patient safe and preserve their quality of life

dignity

Nursing Interventions-Alzheimer’s

Early (Mild) Stage I

Assist the patient to maintain cognitive function

Answer the patient and family’s questions truthfully about the diagnosis of AD

Assess patient’s current level of cognition and sense of smell during H & P
– mini mental test

Develop a consistent and structured environment

Manage coinciding disease processes as they tend to worsen mental functioning

Teach family members the plan of care

Use reminiscent therapy: show pictures of family and patient with labels, talk about object in the room
– find out how patient was before illness

In a long term care setting, place a picture of the patient on their room door

Have adequate lighting

Cover abstract art and mirrors

Oversee medication administration

Nursing Interventions-Alzheimer’s

Middle (Moderate) or Stage II

Need sitters in home setting or long term care arrangements

Power of attorney for finances and oversee care

Frequent reorientation needed

Labels on all familiar items: brush, table, light switches

Need driver at this stage

Do not rely on patient to tell you their needs-toileting, feeding
– anticipate needs

Change diaper frequently or have toileting schedule

Start Alzheimer’s meds if not already

Assist patient in keeping a sleep schedule-may need sedative at night-Ambien

Watch for wandering and sundowning

Keep patients meds out of reach of patient

Nursing Interventions-Alzheimer’s

Late (Severe) Stage III

Turn every two hours and monitor skin

Complete all ADLs for patient

Anticipate needs

Total care

Frequent ROM

Death usually occurs in Alzheimer’s patients due to complications of immobility
– pressure ulcers that get infected and cause sepsis; pneumonia; infection; nobody is feeding them
– prevent complications and increase quality of life and safety

Interprofessional Team-Alzheimer’s
Physical therapist and occupational therapist
– provide evaluation for level of independence and evaluate for assistive devices
– prescribe an exercise program for patient
– ROM

Medical Assistant
– Offer frequent toileting
– Assist with food intake
– Offer liquids
– Assist with bathing, dressing

Nutritionist
– Prescribe high calorie, high protein supplements

Psychiatrist or Neurologist
– Oversee medications

Medications-Alzheimer’s
Aricept (cholinesterase inhibitor)
– slows progression* of disease
– Delays destruction of acetylcholine

Namenda (NMDA receptor agonist)
-slows progression of disease
– Indicated for advanced AD, can be given with Aricept
– shows some improvement in movement and memory*

Paxil, Zoloft (SSRI inhibitors)
– help with depression that accompanies AD
– May take several days to weeks to have full effect

Psychotropics
– only for agitation and aggression
– Sometimes incorrectly used and considered by JC as chemical restraints

Definition-Parkinson’s Disease
Progressive, neurodegenerative disease that affects motor ability and reduces sympathetic nervous system control on heart and blood vessels

If affects the availability of two major neurotransmitters: dopamine and acetylcholine

Cause unknown: suspect genetic or environmental influences
– go by symptoms

**Four Cardinal S/S-Parkinson’s
Tremor
– hands and feet

Rigidity
– stiff

Bradykinesia/Akinesia
– slow movement or no movement

Postural instability

certain drugs cause this symptoms but if stop drugs then these symptoms go away; not true parkinson’s disease just syndrome

Stages of Parkinson’s Disease

Stage 1: Initial Stage

Unilateral limb involvement
– one arm swinging when walking

Minimal weakness

Hand and arm trembling
– “Pill-rolling tremor”

Stages of Parkinson’s Disease

Stage 2: Mild Stage

Bilateral limb involvement
– not swinging either arm when walking

Mask-like face
– no expression on face; flat

Slow, shuffling gate

Stages of Parkinson’s Disease

Stage 3: Moderate Disease

Postural instability
– trouble walking
– walker or cane are difficult to use
– very easy to fall

Increased gate disturbance

Stages of Parkinson’s Disease

Stage 4: Severe Disability

Akinesia

Rigidity

slow and rigid
– wake up in morning and can’t move; need shower and medication

Stages of Parkinson’s Disease

Stage 5: Complete ADL Dependence

frozen
Nursing Interventions-Parkinson’s Goal
improve mobility and maintain safety
– ROM
– medications
– assistive devices
– some have dementia but some don’t
Nursing Interventions: Parkinson’s
Allow the patient extra time to respond to questions.

Administer medications on schedule to maintain drug levels
– drug holiday sometimes

Monitor for orthostatic hypotension

Implement interventions to prevent complications of immobility: constipation, pressure ulcers, contractures, pneumonia

Teach patient to speak clearly and slowly. Use alternate forms of communication.

Monitor the patient’s ability to eat and swallow.
– speech therapy

Assess for depression, anxiety, and insomnia.

Not all patients with Parkinson’s have dementia, but impaired cognitive function and memory deficits are common

***Instruct patient to rock back and forth to initiate movement
– it helps; initiate purposeful movement helps stops involuntary movement

Drugs used in Parkinson’s Disease
Mirapex, Requip and Neupro (dopamine agonist)
– GI disturbance
– full event: agonist

Sinemet combonation dopa/levodopa-(dopaminergics)
– Teach family to give drug before meals to enhance absorption

Eldepryl (MAOI)
– When taking MAOI drugs patients need to avoid tyramine rich foods: such as cheese, aged, smoked or cured foods and sausage, red wine and beer while they are taking drug and 2 weeks after discontinuation
– can’t give Mirapex, Requip or Neupro b/c causes serotonin syndrome

Cogentin (anticholinergic)
– Look for side effects such as changes in vision, elimination, and gastric emptying
– Do not suddenly stop taking them.

APOKYN (apomorphine hydrochloride injection)
– is used as needed to treat off-episode motor symptoms, such as muscle stiffness, slow movements, and difficulty starting movements, in people with advanced Parkinson’s disease (PD). It is used in addition to oral PD medicines

Invasive Treatments-Parkinson’s
Stereotactic palidotomy/thalamotomy
– open skull, target area, destroy area causing tremor and rigidity

Deep Brain Stimulation
– When drug therapy is no longer effective,
– Acts like “pacemaker”

Fetal Tissue Transplantation
– Experimental, highly controversial

Interprofessional Care- Parkinson’s
Dietitian-
– evaluate patient’s food intake and need for nutritional supplements, high calorie, high protein choices

Speech Therapy
– Evaluate patient’s ability to swallow and speak

Occupational and physical therapist
– Encourage patient to be self managed as much as possible, incorporate devices
– Rehab team

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