Delirium and Dementia

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					Introduction-Delirium & Dementia
  A clinically significant deficit in:

  Alzheimer’s most common
  form of dementia
  In 2050, 14 million people expected to have
  this neurodegenerative disease
  After heart disease & cancer, Alzheimer’s the
  3rd most costly disease to society

  More people now surviving into high-risk
  period for dementia (middle age & beyond)
 A disturbance of consciousness and a change
 in cognition that develops:

 Symptoms include:
   Difficulty sustaining & shifting attention
   Extremely distractible
   Must be reminded to focus attention

   Reasoning ability & goal-directed behavior impaired
   Disorientation to time & place common
Delirium (cont.)
 Symptoms (cont.)

   Misperceptions of the environment

   Disturbance in sleep-wake cycle,
   hypersomnolence & insomnia
   Vivid dreams & nightmares common
   State of awareness may range from hypervigilence
   to stupor or semicoma
   Psychomotor activity fluctuate between agitated,
   purposeless movements (restlessness,
   hyperactivity, striking out at nonexistent objects)
   & a vegetative state resembling catatonic stupor
Delirium (cont.)
 Symptoms (cont.)
   Various forms of tremors frequently present

   Emotional instability evidenced by crying, calls for
   help, curing, muttering, moaning, acts of self-
   destruction, fearful attempts to flee or attacks on
   others who are viewed as threatening
   Autonomic manifestations common are:
     Flushed face
     Dilated pupils
Delirium (cont.)

 Other times may be preceded by several
 hours or days of prodromal symptoms

 Slower onset more common if underlying
 cause is systemic illness or metabolic
Predisposing Factors-Delirium
Delirium due to a General Medical Condition

  Post operative states
  Postictal states
  Hepatic or renal disease

Substance-Induced Delirium
  Medication s/e or exposure to a toxin
  See list in text
Delirium due to Multiple Etiologies
  General medical condition combined with substance use
Predisposing Factors-Delirium                             (cont.)
  Substance-Intoxication Delirium
    May arise within minutes to hours after high dose:

    Longer periods of sustained intoxication:

  Substance-Withdrawal Delirium
    Develops after reduction or termination of substance

    Duration directly related to half-life of substance
    May last from few hours to 2-4 weeks
Syndrome of acquired,

with compromised function in multiple spheres
of mental activity:
   Visuospatial skills
   Emotion or personality
   Primary –
Dementia (cont.)
 Language may or may not be affected
 In severe dementia, some individuals may not speak
 at all (aphasia)

   become apathetic & socially isolated
   Previously neat person
   may be come markedly untidy in appearance
   Conversely, individual who had difficulty trusting
   others may then exhibit extreme fear or paranoia
Dementia (cont.)
 The disease progresses:
  Apraxia (inability to carry out motor
  activities despite intact motor function)
  Irritability, moody, sudden outbursts over
  trivial issues
Stages of Dementia
 The progressive nature of symptoms are
 described according to the following stages:

   Stage 1.

   Stage 2.
      May lose things or forget names

     Aware of intellectual decline; may feel
     ashamed, anxious, depressed
Stages of Dementia (cont.)
   Stage 3.
     Concentration may be interrupted

   Stage 4.
     Forget major events in personal hx (child’s bd)

     Unable to understand current news events
Stages of Dementia (cont.)
   Stage 5.

     May forget addresses, telephone #’s, names of
     close relatives

     Frustration, withdrawal &
     self-absorption common
Stages of Dementia (cont.)
   Stage 6.

     Urinary & fecal incontinence common
     Insomnia may be problem

     Communication more difficult with loss of
     language skills
     Institutional care usually required at this stage
Stages of Dementia (cont.)
   Stage 7.

     Bedfast & aphasic (language absent) common
     Problems with mobility (decubitus, contractures)
     Seizures common

     Pneumonia is common cause of death
Dementia- Alzheimer’s type (DAT)
  Early onset (1st symptoms 65 or before)
  Late onset (1st symptoms after age 65)

  Etiologies may include
      Acetylcholine alterations ( )

      Alterations in immune system (production of Ab)
      Head trauma (after years)
Vascular Dementia
 D/T significant cerebrovascular disease

 2nd most common cause of dementia
 Differs from Alzheimer’s d/t more abrupt
 onset & runs highly variable course
Vascular Dementia (cont.)
 Irregular pattern appears to be intense source of

 Neurological signs commonly include:
   Weakness of the limbs
   Small-stepped gait
   Difficulty with speech
 Life expectancy shorter than with Alzheimer’s

 Various disease & conditions interfere with blood
   Arterial hypertension
   Cerebral emboli
   Cerebral thrombosis
Other Related Dementias
Dementia d/t Human Immunodeficiency Virus
 Brain infections d/t opportunistic organisms or HIV-1 virus
 Severity of symptoms is correlated to the extent of brain

Dementia d/t Head Trauma
 Repeated head trauma can result in
                          with symptoms of:
  * Dysarthria                               * Emotional lability
  * Ataxia                                   * Impulsivity
    risk for developing psychiatric disorders:
Other Related Dementias (cont.)
Dementia d/t Parkinson’s Disease
 Dementia in up to 60% of pt’s with Parkinson’s

 Cerebral changes closely resemble those of
Dementia d/t Huntington’s Disease

 Declines to profound state of dementia & ataxia
 within 5-10 yrs
 Death in about 15 years
 Other Related Dementias (cont.)
Dementia d/t Pick’s Disease
 Onset between ages 30-40
 Similar to Alzheimer’s

Dementia d/t Cruetzfeldt-Jacob Disease

 Clinical symptoms typical of dementia
    Involuntary movements, muscle rigidity, ataxia
 Onset occurs between ages 40-60 years;
 Course extremely rapid
 Progressive deterioration & death within 1yr
Other Related Dementias (cont.)
Dementia d/t other General Medical Conditions
    Endocrine conditions (hypoglycemia, hypothryoidism)
    Pulmonary disease
    Hepatic or renal failure
    Cardiopulmonary insufficiency

    Frontal or temporal lobe lesions

    Uncontrolled epilepsy
    Other neurological conditions (e.g., multiple
Other Related Dementias (cont.)
Substance-induced Persisting Dementia

  Substances such as:
    Sedatives, hypnotics, and anxiolytics
    Medications (e.g., anticonvulsants, intrathecal
    Toxins (e.g., lead, mercury, carbon monoxide,
    organophosphate insecticides, industrial solvents)
Dementia d/t Multiple Etiologies
  When symptoms are contributed to more than one cause

Assessment should include:
  Type, frequency, and severity of mood swings
  Personality and behavioral changes
  Catastrophic emotional reactions

  Language difficulties

  Appropriateness of social behavior

  Family medical history
Assessment (cont.)
 Physical assessment:
  Signs of damage to nervous system

  Diseases of various organs can induce:
    Loss of memory
    Behavioral changes
  Causes must be considered in
  dx cognitive d/o
  Neurological examination:
Assessment (cont.)
 Physical assessment (cont.)
   Testing will assess:
     mental status
     muscle strength
     sensory perception
     language skills
   Results of these tests will be used to made a
   differential dx:

   Cognitive symptoms of depression may mimic
Nursing Process
 Diagnostic laboratory evaluations
   Routine blood and urine to tests for:

      Hepatic and renal dysfunctions

      Metabolic and endocrine disorders

      Presence of toxic substances
Nursing Process (cont.)
 Other diagnostic evaluations may include:
   Electroencephalogram (EEG)

   Computed tomography (CT) scan

   Positron emission tomography (PET)

   Magnetic resonance imaging (MRI)

   Lumbar puncture: cerebrospinal fluid (CSF)
 Risk for trauma

 Risk for suicide

 Risk for other-directed violence
Diagnoses       (cont.)

 Disturbed thought processes

 Low self-esteem

 Self-care deficit
The patient is able to:

    Not harm self or others
    Maintain reality orientation to the best of his/her
    Discuss (+) aspects about self & life
Planning/Implementation                 (Care Planning)

Risk for trauma
The following measures may be   To ensure pt safety

  Assign room near nurse’s
  station; observe frequently
Planning/Implementation                     (Care Planning)
Risk for trauma (cont.)
Interventions: (cont.)              Rationales:

                                    To ensure pt safety

  If pt wanders, provide area
  within which wandering can be
  carried out safely
  Soft restraints may be required
  if pt is very disoriented &
Planning/Implementation                    (Care Planning)
Disturbed thought process
Interventions:                  Rationales:
                                  All serve to help maintain
                                  orientation & aid in memory &

                                  Facilitates comprehension;
                                  shouting may create discomfort
                                  or may provide anger
                                  Promotes orientation; reality
                                  orientation sense of self-worth
                                  & personal dignity
                                  Physiological changes can alter
                                  body’s response to certain Rx;
  Monitor for Rx side effects     toxic effects may intensify
                                  altered thought process
Planning/Implementation                 (Care Planning)
Self-care deficit
Interventions:                  Rationales:
   Provide simple, structured
   environment                  To minimize confusion
Planning/Implementation                           (Care Planning)
Self-care deficit         (cont.)
Interventions: (cont.)                   Rationales:

                                         Safey & security are nsg

  Assess prospective caregiver’s
  ability to anticipate & fulfill pt’s   To facilitate transition to d/c from
  unmet needs; provide                   treatment center
  information to assist caregiver’s
  with this responsibility; ensure
  that caregiver’s are aware of
  available community support
  systems to seek help
Medical Treatment Modalities
  1st step is determine & correct of the underlying

  Room should maintain low level of stimuli
  Some physicians prefer Ø Rx, reasoning that
  additional agents may compound problem
  However, agitation & aggression may require
  chemical or mechanical restraint
Medical Treatment Modalities

 General supportive care, provisions for security,
 stimulation, patience & nutrition

 Behavioral approaches for sleep problems:
    Rising same time each am/retiring same time HS
    Eliminating or minimizing afternoon naps
    Regular physical exercise/stimulating activities
    Proper nutrition
Medical Treatment Modalities (cont.)
Pharmaceutical agents
 For: agitation, aggression, hallucinations,
 thought disturbances, and wandering
 For: Dementia – cognitive impairment
Medical Treatment Modalities (cont.)
Pharmaceutical agents (cont.)
  For: depression
  For: anxiety (should not be used routinely for prolonged periods)
     Chlordiazepoxide (Librium)
     Alprazolam (Xanax)
     Lorazepam (Ativan)
     Oxazepam (Serax)
  For: sleep disturbances (for short-term therapy only)
     Flurazepam (Dalmane)
     Temazepam (Restoril)