Cognitive Disorders

1
Cognitive Disorders

• Recognize the signs symptoms
• impaired thinking, memory, and perception
• Psychopathology of Alzheimers dis
• Nursing diagnoses care plan

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Category

• Delirium alterations in consciousness
  cognition reduced ability to focus, sustain, or
  shift attention sensory misperception
  psychomotor agitation.
• Dementia memory cognition disturbances.
  Gradual in onset and progressive in course
• Amnestic disorder memory impairment (inability
  to learn, to recall)
• Others

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Delirium

• Etiology
• physical dis. - Ac or chr. Illness ie. Fever
  DM,
• substance Abuse
• Stress after accident, surgery,
• unknown
• Tx
• Causes med. environment
• Px - poor

4
Common causes of delirium

• Substances CNS stimulants/ depressants
• Infections meningitis, pneumonia
• Meta. Dis hypoxia, hypoglycemia, electrolyte
  imbalance, Vit B1 deficiency (Wernickes
  encephalopahty), hyper/ hypothermia
• Drugs digitalis, lithium,
• Neurological dis seizures, head trauma
• Tumor
• Psychosocial stressors -

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Dementia

• S/S confused, impaired judgment/ attention
  span, alteration in memory/ perception,
• Alzheimers dis
• 50-75 of dementia
• F M
• Average victim living 8-10 years

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4 As in dementia

• Amnesia
• memory impairment
• Aphasia
• language disturbance
• Apraxia
• unable to perform motor activities
• Agnosia
• difficulty in identifying objects

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Alzheimers disease

• Etiology - Genetic Toxin Infection Cholinergic
  function deficit
• Tx Med.
• Tacrine (Cognex), may hurt liver blood check
  every week for 3 months
• donepezil (Aricept), less hepatoxity, enhance
  cholinergic function
• NSAIDs,
• steroids, Vit E, antioxidants
• Family considerations

8
Parkinsons Disease

• S/S involuntary movements, tremor, bradykinesia,
  rigidity, monotone, confused, depressed,
  disoriented
• Etiology extrapyramidal system, dopamine
  deficiency
• 2 of 65 y/o and older F M

9
Huntingtons Disease

• S/S uncontrollable, hyperkinetic, memory loss,
  paranoia, irritability,
• Onset 25-45 y/o F M
• Incidence 5/100,000
• Etiology 50 genetic
• Complications heart failure, pulmonary
  complications - death

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Alcoholic Dementia

• Victim 15-20 years history of drinking
• Etiology - toxic to neurons nutritional
  deficit damage to major organs
• S/S amnesia, slowness of thinking, impaired
  judgment, Wernickes encephalopathy, Korsakoffs
  psychosis (neurodegenerative processes
  confusion, short-term memory loss)

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Delirium Dementia

• Acute onset duration is hours to days
• Fluctuating levels of consciousness
• Disorientation is most severe at night
• Visual, tactile hallucinations
• Could be life-threatening

• Insidious progressive M to years
• Short/long term memory are affected
• No or slow change on EEG
• Aphasia agnosia
• Confabulations or preservation

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Dementia Depression

• Onset slow progressive
• Hide cognitive losses with confabulation
• Affect is shallow labile
• Disorientation
• Attention concentration poor
• Unstable personality
• near miss answers

• Relatively rapid, can trace to distressing event/
  situation
• Can recall recent events
• Pervasive depression
• Oriented to P. P. T
• Personality remains stable
• Dont know answers
• Changes in appetite, BW, sleep pattern

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Common N. Dx

• Health maintenance, Altered
• Self-care deficit
• Social interaction, impaired
• Thought processes, altered
• Communication, impaired
• Coping, ineffective individual/ family

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Nursing Care

• N-Pt R
• Psychopharmacology
• Antipsychotics Atypical typical
• Antidepressant SSRI TCA
• antianxiety agents Ativan, Serax, BuSpar
• Milieu management stimuli, routine, safe,
  stress reduction (inc. physical stressors),
  reminiscence group

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Nursing Care (contd)

• Break tasks into very small steps
• Speak slowly in a face-to-face position
• Allow the client to have familiar objects around
  him/her - reality orientation, self-worth,
  dignity
• Encourage caregivers to express feelings
• Provide a list of community resources, support
  groups,

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Care for the caregiver

• Presenting reality attention to the emotional
  response
• dementia is a primary brain pathology.
• It is a long term care
• Preventing burnout of the caregiver
• Be supportive acknowledge the burden
• Early detection of burnout what the caregivers
  routine life
• Respite care

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Burden to the caregiver

• Physical care basic
• Preventing injury for the client - accidental
  injury
• Others
• Dealing with pts specific behaviors ie
  agitation,
• Do not challenge pts memory

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Delirium acute, night, causes, 25-65 of
elderly hospitalized clients,
Dementia chr, gradual in onset, progressive in
course, elderly, 4As (amnesia, apraxia, aphasia,
agnosia)
Cognitive disorder
Amnestic disorder
Others
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Psychiatric Nursing Special Populations

• Care for victims of violent behavior
• Care for the child adolescent
• Care for the pregnancy
• Care for the elderly

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Problem of Violence

• Types crime, torture, rape, sexual assault,
  childhood sexual abuse, partner abuse
• Prevalence
• Law definition rape is underreported
• 90 of adult intimate violence are males against
  females
• 22-35 of womens visits to ER are domestic
  violence injuries
• 20-50 of the mentally ill reported childhood
  sexual abuse

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Problems in childhood sexual abuse

• the victims usually fear that it will occur if
  they resist the perpetrator
• lack of words and concepts to describe what is
  happening
• adult respond as disbelief, denial, or pressure
  to retract their accusation
• public may discount a childs report as
  unreliable, a fantasy, distorted, or faked at the
  urging of a parent
• child feel special gain affection sensual
  pleasure

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Victims of violent behavior

• Long-lasting impact on the victims
• DSM
• Axis I depression, anxiety, PTSD, somatoform
  disorder, dissociative disorder
• Axis II borderline, narcissistic, avoidant,
  dependent
• Violence victim
• denial, fear, anger, powerlessness, guilty
• hurt trust autonomy
• response of others - alienated isolation

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Recovery process

• Impact shock, denial, disbelief, confusion
• Recoil struggle to adapt need support
  temporarily dependent
• Reorganization reviewing, organizing what
  happened, regaining a sense of control
  self-protection, move from victim status to
  survivor status vs. depression PTSD

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Nursing care

• IPR empathy, support, listening, privacy
• physical safety emotional security
  reassurance, protection from further harm,
  medical care, clear simple direction,
• Referral support group
• Long-term counseling self-esteem,
  self-acceptance, forgiveness of self, adaptive
  coping with life and its stresses, capacity for
  intimate R.
• Multidisciplinary approach - understand clients
  background
• Psychopharmacology for S/S (mood, anxiety)

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Issues related to violence

• Applications of the law, political societal
  attitudes - reporting recovering
• Psychiatric diagnoses victimization,
  stigmatization normal responses vs. psychiatric
  symptoms
• Continuous, long-term counseling
• Problems pass on for generations

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Care for the Teenager -Mental illness morbidity

• One in every 5 young people in the States shows
  S/S of a mental health problem
• Half of these young people will also develop a
  problem with drugs- Surgeon General
• Untreated - poor performance in school, behavior
  problems, relationship problems, or even suicide
• Teenager suicide cases Ca, HD,

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Depression in Children

• Symptoms pretend to be sick, refuse to go to
  school, cling to a parent, worry that the parent
  may die, sulk, get into trouble at school, be
  negative, grouchy, and feel misunderstood.
• Temporary phase vs. depression
• Gain attention - only in the past 2 decades

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Predisposing factors of depression inchildren
and adolescents

• Loss of parents
• Death of other persons or pet
• Move
• Academic problems or failure
• Physical illness/injury

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Young Bipolar

• of cases is increasing
• Difficult to Dx
• Emotional turmoil of teenagers
• Family and school stress, recreational drug use
• Collection of genes that express themselves more
  aggressively in each generation
• Receiving no treatment or have been medicated for
  the wrong illness.

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Mental Illness in Child adolescent

• Developmental disorders pervasive (autistic
  dis. Aspergers dis, Retts dis.) specific
  disorders (dyslexia, comm. Dis.)
• Disruptive behavior disorders ADHD, oppositional
  defiant dis. , conduct dis.
• Internalizing disorders anxiety, mood dis.
• Tic disorders motor, phonic tics, TS
• Psychotic disorders - rare
• Elimination disorders enuresis, encopresis

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Pervasive Developmental Disorder(Global
Impairment of Development)

• Characteristics
• Impairment in social interaction communication.
  It usually persists throughout life.
• Severe sensory integration problem
• Impulsive, irritable, rigid, difficulty
  transition from one activity to another
• Co-existing behaviors, ie., anxiety, mood
  disorders
• Medications for S/S, but do not cure PDDs
• Monitor the side-effects
• Interventions Social skill training behavior
  modification, psycho-education

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Oppositional Defiant Disorder

• Characteristics a pattern of negative, hostile,
  and defiant behavior
• Different from conduct disorder.
• Does not include aggression, destruction of
  property, theft or deceit
• Interventions
• High structure, clear expectations
• Behavior therapy
• Teach/ model anger management

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Etiology of mental illness in children

• Genetic factors
• Environmental factors intrauterine insults
  psychosocial adversity poverty family systems
  unsupportive community
• Multi-factors additive effect
• Resiliency withstand the stresses and emerge
  without major dysfunction

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Treatment Care

• Settings in-pt out-pt home school-based
  clinics after-school programs sp program -
  high level of structure
• Medication pharmacodynamics (dosage)
• Stimulant methylphenidate (Ritalin),
  dextroamphetamine (Dexedrine)
• TCA EKG baseline
• SSRI depression OCD
• Antipsychotics typical atypical (Haldol,
  risperidone
• Cognitive behavioral therapy
• Group therapy for adolescents

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Depression in Women

• Twice as often as men
• Hormonal factors menstrual cycle changes,
  postpartum period, menopause
• Additional stresses work and home, single
  parenthood, caring for kids/aging parents

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Postpartum Psychiatric Disorders Postpartum
blue

• Prevalence 70-80 of all new mothers
• Onset rapid 3-5 days after childbirth
• S/S periodic crying spells, sadness, confusion,
  insomnia anxiety
• Interventions
• Encourage to vent feelings
• Help with housework child care - less
  overwhelmed
• Px recover within a few days

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Postpartum depression

• 7-20 of new mothers easy to be ignored as
  normal sequel of CB
• Onset - within 6 M after childbirth
• S/S anorexia, weight loss, insomnia, fear of
  harming the baby, neglect of personal care,
  self-destructive, feelings of worthlessness,
  guilt, fatigue, hypochondria, low self-esteem
• Px recover relapse

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Postpartum anxiety disorder

• Within 6 M after childbirth
• S/S SOB, palpitations, chest pain, fear of
  losing control, excessive concern about the
  health of the baby, dyspnea, sweating
• Need attention panic attacks, suicidal or
  infantcidal thought
• Untreated disorders - poor relationship with
  baby and older children - behavioral cognitive
  problems of the baby in the future.

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Postpartum psychosis

• 1-2 of mothers per 1,000 live births
• Within 2-4 wks
• Depression, delirium, hallucinations, anger
  toward self baby, thoughts of hurting self or
  baby, bizarre behavior, or mania euphoria,
  grandiosity,
• Tx antipsychotics, psychotherapy, ECT.

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Interventions

• Primary prevention prenatal care
• OPD or inpt Psychopharmacology psychotherapy
• Ind/ gr counseling nonjudgmental, universality
  among another clients
• Assistance with daily housework/childcare
• Family involvement
• Education - Med lactation interaction with
  other drugs no abrupt stop of med. Risk-benefit
  analysis
• Observation mother/infant dyad

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Predicting factors of PP depression

• Hs of PP blues, PP depression, mood disorder or
  premenstrual dysphoric disorder
• Family Hx of depression, bipolar illness
• Marital dissatisfaction
• Anxiety/depression during pregnancy
• Infant-related stressors, i.e. problematic
  temperament in the baby
• Adverse life events
• Lack of support from family or friends

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Mental Illness the Elderly

• Elderly
• 10-20 adversely affected
• Loss in different aspects
• Comorbidity 65 of the mentally ill has other
  dis
• Pharmacokinetics -
• Barriers to mental health care
• Ageism
• Attitudes self others
• Finance
• Inadequate detection

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Pharmacokinetics in the Elderly

• Increased gastric PH
• Increased body fat
• Decreased body H2O
• D. serum albumin
• D. cardiac output
• D. renal function
• D. liver mass, blood flow

• Decreased absorption
• D fat-soluble drug con
• I Water-soluble drug c
• I drug activity
• D meta of drugs
• D excretion of drugs
• D meta. of drugs

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Mental Illnesses in the Elderly

• Depression 15
• 10-20 get Tx
• Bipolar disorder CV neuro problems(?)
• Psychotic disorders meta dis (?)
• Anxiety disorders drugs (?)
• Substance abuse alcohol, OTC, drug abuse
  -tolerance, dependence,

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Depression and the Elderly

• Prevalence of MDD - 6-11.5
• Chronic disease body/mind
• Overlapping symptoms of physical illness
• Medical illness - depression - prolong the
  process
• Side effect of medication
• Risk of suicide
• over 50 years old - 28 of annual death
• 1/8 successful suicide attempts
• 1/2 for over 65 years old, reaching a peak after
  age 85

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Predictors for elderly suicide

• Chronic sleep problems
• Pain
• Degenerative illness
• Clinical depression

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Psychopharmacotherapy in the Elderly

• Antidepressant - SSRI (Zoloft), TCA (Wellbutrin)
  , MAOI (Nardil), psychostimulants
• Antipsychotics high vs low potency
• Antianxiety benzodiazepines (short acting, ie.,
  Ativan), non benzodiazepine ie. buspirone
  (BuSpar)
• Antimanic agents lithium (0.4-0.8mEq/L)

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Problems in drug-taking

• Sensory degenerated vision, hearing
• Disability
• Polypharmacy
• Names of the drugs generic/trade names
• Sharing medications
• Compliance 60 noncompliance
• Living alone

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Nursing process in caring for the elderly

• Assessment physical psychosocial
• Strategies Listening, reminiscing,
• Source client, family separately vs. together
• Goals realistic, attainable,
• Plan intervention
• IPR - self-esteem, self-worth,
• Reminiscence self-esteem, socialization
• Basic needs
• Pharmacokinetics
• Milieu management reality orientation

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Mentally Ill HIV

• Psychiatric disorder - Poor judgment,
  hypersexuality, impulsivity
• 20 of mentally ill were engaging in high-risk
  behavior. Esp bipolar illness
• Education for prevention
• Safe sex abstinence, monogamous relationship
• Eliminate treat the substance abuse

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Patients with HIV

• Neuropsychiatric aspects
• Grief reaction
• AIDS dementia (50-85 of PWAs)
• Management - confidentiality
• Universal precaution
• Medication
• AZT
• methylphenidate (Ritalin)
• Haloperidol (Haldol)

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Forensic Nursing

• Background overlap between the criminal justice
  mental health systems criminalization
  deinstitutionalization
• Clients victims, perpetrators, and their
  families
• Related issues legal, ethical, political,
  administrative, professional

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Characteristics of the forensic setting

• Physical setting
• Client population
• Authoritarian interpersonal environment

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Characteristics of the forensic population

• Poor judgment, limited reasoning abilities,
  history of not learning form past mistakes,
• High level of substance abuse
• Depression, suicidal ideation, aggressiveness,
  irritability, violence
• Personality disorder chr mental illnesses,
  mental retardation, brain injuries,
• Decreased social skills or physical strength
• Criminalized lifestyle

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Crisis Intervention

• Characters of crisis
• a threat to homeostasis - anxiety, confusion,
  loss of problem solving ability
• Crisis danger opportunity
• Short 4-6 weeks

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Phases of a crisis

• Increased anxiety - coping
• Coping failed - further increased anxiety
• Escalated anxiety - reach out for help
• Active state of crisis

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Balancing factors

• Realistic perception of the events
• Coping skills
• Support systems

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Nursing diagnoses

• Ineffective coping
• Anxiety
• Disturbed thought processes
• Situational low self-esteem
• Social isolation
• Impaired social interaction

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Types of crises

• Maturational or developmental crisis various
  task in different states
• Situational crisis - sudden traumatic event ie
  job loss
• Adventitious crisis precipitated by an
  unexpected event ie, natural disasters

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