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7/29/2019 Delirium & Dementia-Class 1
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DELIRIUM ANDDEMENTIA
PSYCHIATRY
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Definition Delirium is an acute confusionalstate,usually happening suddenly within
hours or days.
Its as a result of various physicalcauses,including infection,an endocrine
disorder,trauma and drug abuse.
Some of the causes are CHF,UTI,Liverfailure,electrolyte imbalances, use of
psychotropics & anticholinergics
(Benadryl,Elavil),alcohol withdrawal
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Clinical features
Disturbance of consciousness reduced ability to focus, sustain or shift attention
Cognitive impairment memory deficits, disorientation (for time, place and person), language
disturbances Perceptual disturbances
misinterpretations, illusions and hallucinations (usually visual)
Disturbance in sleep-wake cycle
Altered psychomotor activity increased or decreased)
Disorganized thinking with incoherence and delusions
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Associated features
Emotional disturbances common anxiety, depression, irritability, anger
Neurological signs uncommon Abnormal movements, tremor, autonomic signs
Disorders of higher cortical function Dysnomia(difficulty in naming objects),
Dysgraphia(difficulty in writing)
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Epidemiology
Common condition especially children and elderly
Pre-existing brain damage, drug or alcohol addiction,recovery from anaesthesia, coma
Death rate varies: 10-30%, up to 50% in 1st year
Delirium is a medical emergency, irrespective of age
Course abrupt onset
fluctuating characteristic with lucid intervals
duration usually brief (dependant on identification and treatment ofunderlying condition)
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Diagnostic criteria for Delirium The person has a reduced ability to maintain attention to external stimuli
and to shift attention to a new stimuli. The person exhibits disorganized thinking as indicated by
rambling,irrelevant or incoherent speech.
The person experiences at least 2 of the following
Reduced level of consciousness
Perceptual disturbances-misinterpretations,illusions or hallucinations
Increased or decreased psychomotor activity
Disoriented to time place or person
Memory impairment-inability to learn new material
Clinical features develop over a short period and tend to fluctuate over theday.
The history,physical examination or lab. tests show evidence of 1 or morespecific organic factors related to he disturbance
It cannot be accounted for any other non-organic mental
disorder(eg,agitation in mania)
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NURSING DIAGNOSIS
Disturbed thought processes related to changesin brain function.
Impaired verbal communication related to
incoherent speech. Dressing or grooming self care deficit related
to inability to perform activities of daily living.
Disturbed sensory perception (visual) relatedto disorientation
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DELIRIUM (mnemonic) D -Disoriented(place,time & person)
E -emotionally labile
L -level of consciousness impaired,fluctuates
I -Integration of perceptions is lost
R-rapid onset(hours,days)
I -irrelevant stimuli distract patient
U -utterances(incoherent speech)
M -memory impairment (especially immediate
recent)
Delirium may be life threatening and requires
immediate medical attention
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Treatment
Specific measures
Identify and treat the underlying
conditionThorough medical history, physicaland neurological examination, lab
tests
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Treatment General measures
Ensure sleep
Maintain fluid and nutritional state
Provide support and nursing care
Rest in a quiet, well-lit environment
Maintain orientation
Sedate the agitated, fearful patient
Offer soothing words and expressions of caring
Do not argue ,do not reason
Speak slowly and distinctly
Provide a simple,consistent and predictable environment Provide familiar objects such as pictures,draw on old memories
Help with orientation using clock and calendar
Call patient by name
Safety is the first priority
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PROGNOSIS
Is good
Delirium can have various causes andusually goes away when the condition istreated
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PREVENTIONS
Avoid taking too many different types of drugs
Recognize signs of delirium so treatment canbe started sooner
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DEMENTIA
It is a syndrome characterized by loss of
intellectual abilities to such an extent that social
and occupational functioning is interfered with. It
involves memory, judgment, abstract thought and
changes in personality
Often the disorders are progressive and follow anirreversible course in which the damage remains
permanent
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ETIOLOGICAL FACTORS
1.Neurological diseaseslike Huntingtons chorea, multiplesclerosis and Parkinson's disease.
2.Cardiovascular disorders causing anoxia and brain damagee.g.cerebral arteriosclerosis and CVA.
3.Central nervous system infection like viral encephalitis and
fungal meningitis
4.Brain trauma-chronic subdural hematoma
5.Toxic-metabolic disturbances like bromide intoxication,hypothyroidism, Wilsons disease- hepatocellular degeneration
characterised by deficient metabolism of copper 6.Loss of brain tissue and function in presenile conditions
e.g. AD
7.Alteration of intracranial pressure e.g hydrocephalus,brain tumor
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CHARACTERISTICS
Memory impairment and insidious loss of
intellectual ability
Onset tends to be gradual (such as from AD or
AIDS)
Progressive, static or recurring course, depends
on pathogenesis
Prevalence among elderly patients (but can
occur in any age group)
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SIGNS AND SYMPTOMS
Short and long term memory impairment
Premorbid personality changes
Disturbed judgment Difficulty in understanding the meaning of
words
Confusion Depressed affect
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DIAGNOSTIC CRITERIA
A.The person shows demonstrable evidence of short
and long term memory impairment B.He exhibits at least one of the following
-Impairment in abstract thinking
-Impairedjudgment
-disturbances of higher cortical function like
Aphasia-disorder oflanguage
Apraxia-inability to carry out motor activities
despite intact comprehension and motor functionAgnosia-failure to recognize or identify objects and
constructional difficulty
-Personality change
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C. The disturbance in a& b significantly interferes
with the the persons work or usual social activities or
relationships with others. D.The disturbance does not occur exclusively during
the course of delirium
E.The disturbance meets either of the following
criteria
-history, physical examination or lab tests show
evidence of one or more specific organic factors.
-it is not accounted for by any non organic mentaldisorder (eg major depression accounting for
cognitive impairment)
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Diagnosis
Loss of intellectual abilities that interfere with
social and occupational functioning
Memory impairment
Impairment in abstract thinking,judgment and
language
Personality change demonstrated by
exaggeration of previous personality traits
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Health care professionals use the following criteria
MILD: Work or social activities are significantlyimpaired but the capacity for independent living
remains with adequate personal hygiene and intact
judgment
MODERATE: Independent living is hazardous and
some degree of supervision is necessary.
SEVERE: Activities of daily living are so impaired
that continual supervision is required, the personcannot maintain minimal personal hygiene.
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DEMENTIA
A-apraxia
M-memory impairment
A-agnosia
G-gradual onset & continual decline
R-rule out delirium, substance abuse & medical
conditions
A-aphasia
D-decline in social & occupational functioning
E-executive function declines (ie, planning,
organizing, sequencing)
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FORMS OF DEMENTIA
1.Alzheimers disease-most common
2.Vascular dementia is sometimes known as
multi-infarct dementia.It is related to an
interruption of blood flow to the brain e.g.
cerebral embolism, cerebral thrombosis. It isabrupt in onset and runs a variable course.
3.Picks disease is a rare form of dementia that
affects the frontal and the temporal lobes of thebrain.The clinical picture is fairly similar to
AD but differences can be detected at autopsy
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4.Creutzfeldt-Jakob disease(CJD) has symptoms that
often include spasms of the body. It is caused by a
slow acting virus that can live in the body for years
before any signs of the disease become obvious .
Once the signs of CJD become apparent its progress
is rapid. 5.Huntingtons chorea is a genetically transmitted
disorder transmitted by a single autosomal dominant
gene. Personality, memory and mood changes as the
disease advances. In later stages severe twitches,spasms and involuntary movement of the limbs
become apparent.
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ALZHIEMERS DISEASE
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In 1906 Dr. Alois Alzheimer was first todescribe Alzheimer's disease.
Since then millions of people have been
diagnosed with the disease.
Understanding
Alzheimer's
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A progressive, degenerative disease that
attacks the brain and results in impaired
memory, thinking and behavior.
There is loss of intellectual functioning ,
orientation, affective regulation, motor
coordination and personality with eventual
loss of bowel and bladder control to the point
of total incapacitation
What Is Alzheimer's
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What Are the Warning Signs? Memory loss that affects job skills- recent
Difficulty performing familiar tasks, short attention span Problems with language
Disorientation to time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood or behavior, depression, paranoia,
combativeness
Changes in personality
Loss of initiative
Forgetfulness is the first symptom observed in A.D
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Sundowners syndromeConfused , disoriented behaviour that becomes
noticeable after the sun goes down and during the night
Wandering behaviorRestlessness and activity seeking behavior
The stalking of old haunts, night wandering
Catastrophic reactions
Heightened anxiety occurring during interviewing orquestioning when a person cannot answer or perform
Incontinence
Inability to perform ADL
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What Causes Alzheimer's?
Scientists are still not certain.
Age and family history have been identified as
potential risk factors. Researchers are exploring the role ofgenetics.
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Does Alzheimer's Disease
Occur in Younger Adults? Yes, though less frequently.
The disease can occur in people in their 30s,
40s and 50s. Most people diagnosed are older than 65.
The form of the disease that strikes younger
people accounts for less than 10 percent of allreported cases.
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MANAGEMENT OF DEMENTIA
1.Treatment is generally community focussed: The goal oftreatment is to maintain the quality of life as long as possible
despite the progressive nature of disease. Effective treatment is
based on:
a.Diagnosis of primary illness and concurrent
psychiatric disorders
b.Assessment of auditory and visual
impairment.
c.Measurement of the degree, nature and
progression of cognitive deficits
d.Family and social system assessment.
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2.Environmental strategies in order to assist inmaintaining the safety and functional abilities of the
patient as long as possible.
3.Pharmacological therapy: For patients of DATanticholinesterase medications is used to slow the
progression of the disorder by increasing the amount of
acetylcholine e.g. Donepezil (aricept), Tacrine (cognex).
Other medications may be used for symptom reductionand behavioral control
Agitation management- Neuroleptics
Psychosis- neuroleptic agents
Depression- antidepressants, ECT
4.Hypertension management in vascular dementia is
important in decreasing the severity of symptoms.
5.Family education is very important
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NURSING DIAGNOSIS Impaired communication related to cerebral impairment
as demonstrated by altered memory, judgment and word
finding.
Self-care deficit related to cognitive impairment asdemonstrated by inattention and inability to completeADLs
Risk for injury related to cognitive impairment andwandering behavior
Impaired social interaction related to cognitive impairment
Risk for violence:Self directed or directed towards othersdue to suspicion and inability to recognize people or places.
Altered Family process related to impact of cognitivedeficits on traditional roles and functioning
Caregiver role strain related to lack of support and level of
care necessary for the patient.
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NURSING INTERVENTIONTo provide a quiet structured environment to
increase consistency and promote feeling ofsecurity Avoid dependency
Establish routine for ADL
Meet clients physical needs Do not isolate client from others in the unit
Provide hand rails,walkers and wheelchairs
Do not change schedule suddenly- routine,
reinforcement and repetition are the key aspects ofcare
Check for hazards in the environment (rugs on floor) makesure environment is well- lighted
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To promote contact with reality Orient client frequently to reality and surroundings. Allow clients to have
familiar objects around him/her. Use other items e.g.clock, calendar daily
schedules Maintain reality orientation by encouraging reminiscing. Reminiscence and
life review help the client resume progression through the grief process
associated with disappointing life events and increase self esteem as
successes are reviewed.
Monitor the activities of a confused client
Make brief and frequent contact.
Give feedback
Use simple explanations and face to face interaction. Do not shout message
into clients ear. Speaking slowly and in face to face position is most
effective when communicating with an elderly client experiencing a
hearing loss.Visual cues facilitate understanding. Shouting causes
distortion of high pitched sounds and creates discomfort in some clients.
Allow sufficient time for client to finish projects.
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To provide diversion activities that enhanceself esteem.
Provide occupational therapy, physical therapy andrecreational therapy that the client enjoys.
Maintain a flexible schedule: keep client from becoming boredand easily distracted.
Recognize specific accomplishments.
Encourage family involvement and provide support Devise methods for assisting client with memory deficits like
Name sign and picture on door identifying clients room andthe other rooms.
Large clock with oversized numbers and hands,appropriatelyplaced.
Large calendar indicating one day at a time with month dayand year identified in bold print.
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Ensuring safety
Discuss restriction of driving
Assess home for safety:keep house well lit, remove throw rugs, labelrooms.
Assess community for safety
Alert neighbors about patients wandering behavior
Alert police and have current pictures taken.
Provide patient with a Medic-Alert bracelet Install complex safety locks on doors to outside or basement.
Install safety bars in bathroom.
Closely observe patient if he or she is smoking.
Encourage physical activity during the daytime
Give the patient a card with simple instructions (address and phonenumber) in case he or she is lost.
Use night lights
Install alarm/sensor devices on doors
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To improve the nutritional status
Provide small, frequent feeds
Serve finger foods/semi-soft/pureed foods
Assess ability to swallow
Use feeding aids when necessary
Put the patient on a consistent meal schedule
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The 3 Ps for clients with dementia Protecting dignity
Preserving functioning
Promoting quality of life
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COMPLICATIONS
Malnutrition/dehydration
Pressure ulcers
Muscle contractures Physical injuries
Abuse
Infection Death
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AMNESTIC DISORDERS Short and long term memory impairment
without clouding of consciousness orintellectual deterioration
Result of a specific insult to the brain
Anterograde memory loss- the patient cantremember events that occurred after the braininsult
Retrograde memory loss- the patient cantremember events that occurredbefore the braininsult
Confabulation is commonly used as a defense
mechanism.
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Signs and Symptoms
Inability to recall recent events
Inability to retain newly learned material
Observable or laboratory test evidence of
organic brain insult
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Diagnostic criteria
The person shows demonstrable evidence of short and long
term memory impairmentShort-term memory impairment-indicated by
an inability to remember 3 objects after 5
minutes.
Long-term memory impairment-indicated by
an inability to remember personal information
or facts of common knowledge
The disturbance does not occur exclusively during the courseof delirium and does not meet the criteria for dementia
The history, physical examination or lab tests show evidence
of one or more factors judged to be etiologically related to the
disturbance
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Nursing Diagnosis
Imbalanced nutrition: less than bodyrequirements related to nutrientdeficiency
Impaired adjustment related to memoryloss
Risk for injury related to inability to learn
safety rules Compromised family coping related topoor family adjustment to the patients
behavior
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Nursing Intervention
Monitor the patients food and fluid intake
Supervise the patients travel away from home
Establish a training program for relearning
information needed to exist safely in the
environment
Institute memory therapy by teaching
mnemonics
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