Chapter 12

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Delirium, Dementia, and Amnestic disorders

an example of treatable (reversible) form of dementia is one that is cause but which of the following? Select all that apply.
a. multiple sclerosis
b. multiple small brain infarcts
c. electrolyte imbalances
d. HIV disease
e. Folate deficiency

c.electrolyte imbalances
e. Folate deficiency

Mrs. G has been diagnosed with dementia of the Alzheimer's type. The cause of this disorder is which of the following?
a.multiple small brain infarcts
b.chronic alcohol abuse
c.cerebral abscess
d.unknown

d.unknown

Mrs. G has been diagnosed with dementia of the Alzheimer's type. The primary nursing intervention working with Mrs. G is which of the following?
a.ensuring that she receives food she likes, to prevent hunger
b.ensuring that the environment is safe, to prevent injury
c.ensuring that she meets other patients, to prevent social isolation
d.ensuring that she takes care of her own ADLs, to prevent dependence

b.ensuring that the environment is safe, to prevent injury

which of the following medications have been indicated for improvement in cognitive functioning and mild to moderate Alzheimer's disease?
a.donepezil
b.Rivastigmine
c.risperidone
d.sertraline
e. tacrine

a.donepezil
b.Rivastigmine
e. tacrine

Mrs. G, who has Alzheimer's disease, says to the nurse, "I have a date tonight. I always have a date on Christmas." Which of the following is the most appropriate response?
a. don't be silly. It's not Christmas, Mrs. G
b. today's Tuesday, October 21, Mrs. G. We'll have supper soon, then your daughter will come visit
c. who is your date with Mrs. G
d. I think you need some more medication, Mrs. G. I'll bring it to you now

b. today's Tuesday, October 21, Mrs. G. We'll have supper soon, then your daughter will come visit

in addition to disturbances in cognition and orientation, individuals with Alzheimer's disease may also show changes in which of the following? Select all that apply
a.personality
b.vision
c.speech
d.hearing
e. Mobility

a. personality
c. speech
e. Mobility

Mrs. G, whereas Alzheimer's disease, has trouble sleeping I wondered around the night. Which of the following nursing actions would be the best to promote sleep in Mrs. G?
a. ask the doctor to prescribe flurazepam
b.ensure that Mrs. G gets in an afternoon nap so she will not be overtired at bedtime
c.make Mrs. G cup of tea with honey before bedtime
d.ensure that Mrs. G gets regular physical exercise during the day

d.ensure that Mrs. G gets regular physical exercise during the day

tonight nurse finds Mrs. G, a client with Alzheimer's disease, wandering the hallway at 4 AM and tried to open the door to the side yard. Which statement by the nurse probably reflects the most accurate assessment of the situation?
a. that door leads out to the patio, Mrs. G. It's night time. You don't want to go outside now
b. you look confused, Mrs. G. What's bothering you?
c. this is the patio door, Mrs. G. We're looking for the bathroom?
d. are you lonely? Perhaps you'd like to go back to your room and talked for a while.

c. this is the patio door, Mrs. G. We're looking for the bathroom?

a client says to the nurse: I read an article about Alzheimer's, and it said that the disease is hereditary. My mother has Alzheimer's disease. Does that mean I'll get it when I'm old? The nurseher response on the knowledge that was to the following factors is not associated with increased incidence of dementia of the Alzheimer's type?
a. multiple small strokes
b. family history of Alzheimer's disease
c. head trauma
d. advance age

a. multiple small strokes

Mr. Stone is a clients in the hospital with a diagnosis of vascular dementia. In explaining this disorder to Mr. Stone family, which of the following statements by the nurse is correct?
a.he will probably live longer than if his dementia was of the Alzheimer's type
b.vascular dementia show stepwise progression. This is why sometimes seems okay
c.vascular dementia is caused by plaques and tangles that form in the brain
d.the cause of vascular dementia is unknown

b.vascular dementia show stepwise progression. This is why sometimes seems okay

which of the following interventions is most appropriate in helping a client with Alzheimer's disease with her ADLs? Select all that apply
a.perform ADLs for her while she is in the hospital
b.provide her with a written list of activities she is expected to perform
c.assist her with step-by-step instructions
d.tell her that if her morning care is not completed by 9 AM it will be performed for her by the nurse's aid so that she can attend group therapy
e.encourage her and give her plenty of time to perform as many of ADLs as possible independently

c.assist her with step-by-step instructions
e.encourage her and give her plenty of time to perform as many of ADLs as possible independently

delirium

mental state characterized by disturbance cognition, which is manifested by confusion, excitement, disorientation, and clouding of consciousness. Hallucinations and delusions are common

Mr.M is elderly patients who will be undergoing surgery. The nurse explains to him that he might have symptoms of delirium. Mr. M asks the nurse what to expect?

S/S of delirium difficulty sustaining a shifting attention, extremely distractible, disorganized reflected by rambling, irrelevant, pressured, incoherent and that unpredictably switches from one subject to another. Disorientated time and place. Misperception of environment, including illusions and hallucinations

how is a level of consciousness affected by delirium?

LOC may range from hypervigilance to stupor or semicomatose

how is the psychomotor affected by the delirium?

activity may fluctuate between agitated purposeful movements (striking out a nonexistent objects) and vegetative state resembling catatonic stupor.

what is the onset and duration of delirium, average?

symptoms begin abruptly and duration is usually brief between one week and one month.

what kind of emotions can you expect to find in a patient with delirium?

fear, anxiety, depression, irritability, anger, euphoria, or apathy. They may be evidenced by fearful attempts to flee self-destruction, cursing, moaning etc. etc.

Categories of Delirium

delirium due to a general medical condition
substance induced delirium
substance intoxication delirium
substance withdrawal delirium
delirium due to multiple etiologies

what are medical conditions that can cause delirium?

systemic infections, metabolic disorders, freeware electrolyte imbalances, hepatic or renal disease, thiamine deficiency, post operative states, hypertensive encephalopathy, postical states, sequelae of head trauma, and others

substance induced delirium is attributed to medications side effects or exposure to toxins. Toxins include

it's an aesthetics, analgesics, anti-asthmatic agent, anticonvulsants, antihistamines, antihypertensive and cardiovascular medications, antimicrobials, anti-Parkinson's drugs, corticosteroids, gastrointestinal medications, as histamine, H2 receptor agonist, and many others. Toxins that can cause delirium kennel phosphate, insecticides, carbon monoxide and fuel or organic substances

the patient appears to be showing signs of delirium, a friend reports that he took high doses of certain drugs that could include cannabis, cocaine, hallucinogens. what category will this delirium fall under?

substance intoxication delirium

recovering alcoholics, crack addicts, and junkies may suffer from this category delirium.

substance withdrawal delirium

when delirum is the product of more than one cause it is called?

delirium due to multiple etiologies

dementia

a loss of previous levels of cognitive, executive, and memory function in the state of full alertness.

what is the third most costly disease in the country?

Alzheimer's disease accounting for hundred billion in yearly cost.

Primary dimentia

dementia herself is the major sign of some organic brain disease not directly related to any other organic illness for, example Alzheimer's disease

secondary dementias

caused by or related to another disease or condition, such as HIV disease or cerebral trauma

signs and symptoms of dementia are

impairment in abstract thinking, judgment, and impose control. Language may or may not be affected, and severe forms aphasia may occur. Personality can be altered or accentuated.

apraxia

inability to carry a motor activities despite intact motor function

an elderly patients with dementia in a nursing home becomes very moody he has sudden outburst over trivial issues. The patient is frustrated because he cannot perform simple tasks. What is the patient experiencing more can be done about that?

patient is experiencing apraxia, and he can no longer be left alone because he might not comprehend his limitations. Patient is monitored for wandering.

One of the seven stages of Alzheimer's progression?

Stage I. No Apparent Symptoms
Stage II. Forgetfulness
Stage III. Mild Cognitive Decline
States IV. Mild to Moderate Cognitive Decline confusion
Stage V. Moderate Cognitive Decline, Early Dementia
Stage VI. Moderate to Severe Cognitive Decline Middle Dementia
Stage VII. Severe cognitive decline; late dementia

Stage I. No Apparent Symptoms

no apparent decline in memory

Stage II. Forgetfulness

individual loses things and forgets the names of people. Loses short-term memory. Aware of intellectual decline in May flushing. Symptoms are usually not observed by others.

Stage III. Mild Cognitive Decline

usually interference with work performance which is noticeable. Individual may get lost while driving. Difficulty recalling names or words which also becomes noticeable to family members. decline ability to plan and organize.

States IV. Mild to Moderate Cognitive Decline confusion

may forget major events and personal history such as child's birthday; experienced the clan ability to perform task such as shopping or managing finances; unable to understand current events. May become defensive and denied problems exist, and depression may occur.

Confabulation

creating imaginary events to fill memory gaps

Stage V. Moderate Cognitive Decline, Early Dementia

individual loses ability to perform some ADLs, and may require some assistance. May become disoriented about place and time, but maintain knowledge about themselves. Frustration, withdraw, self absorption are common.

Stage VI. Moderate to Severe Cognitive Decline Middle Dementia

unable to recall recent major life events or even the name of his or her spouse. Disorientation to surroundings, and may be unable to recall day season or year. Unable to manage ADLs without assistance. Sleeping becomes a problem. Psychomotor symptoms develop and may become worse and late afternoon. Communication becomes more difficult.

sundown syndrome

phenomenon in which dementia symptoms worsen in the late afternoon and evening

Stage VII. Severe cognitive decline; late dementia

unable to recognize family. Commonly bedfast and aphasic. Immobility problems may occur.

dementia for the Alzheimer's type

onset of symptoms slow and insidious, progressive and deteriorating.

how is Alzheimer's dementia diagnosed

CT or MRI scans are used to reveal degenerative pathology of the brain that can include atrophy, widen cortical sulci, and enlargement of cerebral ventricles. Microscopic examinations revealed numerous neurofibrillary tangles and senile plaques in the brain that occur in a dastardly increased number.

what's the etiology of Alzheimer's disease?

exact etiology is unknown but several hypothesis are available such as acetylcholine alterations, plaques and tangles, head trauma, and genetic factors.

acetylcholine alterations

The enzyme required to produce acetylcholine is dramatically reduced in patients in A.D. clients. This reduction acetylcholine prevents the cortex and hippocampus from receiving the appropriate amount resulting in disruption of cognitive processes.

plaques and tangles

overabundance of these appear in the brain. The rate of protein called amyloid beta. It is not known whether the plaques and tangles calls A.D. or are a consequence of the A.D. process.'s is thought that they do contribute to the destruction and death of neurons.

Head trauma

this has been associated with ADD. It has been reported that individuals who experience head injuries and not genetically predisposed to A.D. have a higher chance of acquiring the disease

genetic factors

clearly a familial pattern with some forms of Alzheimer's disease. Some studies indicate fairly are more likely to be familial. Individuals with down syndrome have been found to be unusually susceptible to A.D.

vascular dementia

due to significant cerebral vascular disease. Second most common form.

How does Vascular dementia differ from Alzheimer's disease?

more abruptt onset and runs a highly variable course. Progression occurs in steps rather than graduate to deterioration. Client may have moments of clarity which rises hopes but then deteriorates further which could give him intentions anxiety. the client suffers multiple small strokes destroy many areas of the brain. Characteristics depend on which part of the brain is being targeted.

What is the etiology of vascular dementia?

Directly related to an interruption of blood flow to the brain. Symptoms result from the region of the brain that affected.

hypertension and vascular dementia

one of the most significant factors is high blood pressure. It leads to damaging the lining of blood vessels. Which can lead to rupture hemorrhage or accumulation the fibrin vessels which can inhibit blood flow.

what is Dementia due to HIV

severity of symptoms correlated with the extent of brain pathology. Your brain is infected by other organisms the immune system can only defend against.

what is dementia due to head trauma

amnesia is the most common neurobehavioral symptom following head trauma. Repeated trauma such as the weight boxers experience can result in dementia pugilistica.

what is Dementia due to the Lewy body disease

is very similar to AD the difference being that it progresses more rapidly, visual hallucinations are present, and parkinsonian features are also present.these patients are highly sensitive to extrapyramidal effects of antipsychotic medications.

what is dementia due to Parkinson's disease?

is observed over 60% of patients with Parkinson's disease. Caused by loss of nerve cells located in the substantia nigra.

What is dementia due to Huntington's disease

genetically transmitted as a Mendelian dominant gene. Damage is usually seen in the basal ganglia and the cerebral cortex. Average duration of the disease is based on age at onset.

what is dementia due to pick's disease

genetic factor believed to be involved, major difference between A.D. is the initial symptom is a personality change, or as initial symptom and A.D. is memory impairment. Atrophy of the temporal and frontal lobes of the brain are usually seen.

for some other Gen. medical conditions that can cause dementia?

Endocrine conditions such as hypoglycemia, hypothyroidism. Pulmonary disease, hepatic or renal failure, cardiopulmonary insufficiency, fluid and electrolyte imbalances, nutritional deficiencies, frontal temporal lobe lesions, central nervous system or systemic infections, uncontrolled epilepsy or other conditions that can cause dementia.

Substance induced persisting dementia

it could be alcohol, inhalants, sedatives, medications, toxins.

Amnesia

the inability to retain a recall past experiences. This condition may be temporary or permanent, depending on the etiology

how are you amnestic disorders characterized?

By inability to learn new information (short-term memory deficits) despite normal tension and an inability to recall previously learned information (long-term memory deficit).

how was the patient with profound amnesia expected to answer questions?

usually disoriented to place and time narrative itself. They may engage in calm fibrillation. Some may deny having a problem even when provided with evidence, and some egg knowledge it would not appear to care. They may appear emotionally bland

amnestic disorder due to general medical condition

India's Muslims is from the history, physical examination, or laboratory findings to show that the memory impairment as a consequence of general medical condition.

What would the nurse look for the medical history if she suspects a amnestic disorder due to a general medical condition?

Head trauma, cerebral vascular disease, cerebral neoplastic disease, cerebral anoxia, herpes simplex encephalitis, poorly controlled insulin-dependent diabetes, and surgical intervention to the brain.

Substance induced persistent amnestic disorder

in this disorder evidence must exist from the history, physical examination, or laboratory findings that the memory impairment is related to persistent effects of substances such as alcohol, sedatives hypnotics and anxiolytics, medications, and toxins

the client would the mentors unable to answer questions about his medical history. How should the nurse proceeded in acquiring this information?

data should be obtained from family members or others who would be aware of the plans physical and psychosocial history

what areas of concern should the nurse prioritize when obtaining history of a patient with dementia

type, frequency, and severity of mood swings, personality and behavioral changes, and catastrophic emotional reactions; Cognitive changes, such as problems with attention span and thinking process; Language difficulties; orientation to place time and situation; and appropriateness of social behavior

in order to help acquire and etiology which the nursing assessment focus on?

Current impasse medication usage, history of other drug and alcohol use, and possible exposure to toxins such as workplace.

What are the two main emphasis. There should focus on when it comes to physical assessment on patient with dementia or delirium?

Signs of damage to the nervous system and evidence of disease of other organs that could affect mental functioning.a thorough physical assessment is imperative in order to not misdiagnose patients especially elderly patients with pseudo-dementia or dementia.

what type of laboratory diagnostic studies may a physician order in order to diagnose a patient with dementia?

CBC, urine samples, hepatic function panel, diabetes, electrolyte imbalances, endocrine disorders, nutritional deficiencies, persons of toxic substances including alcohol and other drugs. Doctor may also order a CT scan, EEG.,lumbar puncture and PET

dealing with delirium was the first step in treatment?

The determination correction of the underlying causes. Some patients with delirium may require chemical or mechanical restraints and they get too aggressive.

What is the treatment priority for patients with dementia?

What's diagnosis has been made focus hard to do for you: to see if the process is reversible.

With the therapeutic implication cholinesterase inhibitor?

shown to enhance cognitive functioning in patients with mild to moderate A.D.

how to lose cholinesterase inhibitors work in improving cognitive functioning in patients with AD?

They inhibit acetylcholinesterase which slows the degradation of acetylcholine, thereby increasing concentration of the neurotransmitter in the cerebral cortex. These drugs lessen the disease process but do not alter the course of progression of the disease

cholinesterase inhibitors include

tacrine, donepezil, rivastigmine, galantamine.

NMDA receptor agonist,memantine (Namenda) helps treat cognitive deficit not in Alzheimer's by doing what?

memantine blocks NMDA receptors decreasing the cost levels in cells. It does not reverse the effects of disease and only slows it down. Because the taxes are different than cholinesterase inhibitors it can be given together.

How his agitation, aggression, hallucinations, thought disturbances, and wandering controlled in patients with delirium or dementia?

positions used to treat them with antipsychotic medications such as risperidone, olanzapine, quetiapine, and ziprasidone but these antipsychotics have been black labeled due to their increased death in elderly patients with dementia. Now there are only administered when previous behavioral programs have felt that with consent of the patient's family.

what are the side effects experienced with anticholinergic?

Confusion, blurred vision, constipation, dry mouth, dizziness, difficulty urinating. Older people should especially sensitive to these effects.

what antidepressant medications are used for the treatment of depression and dementia?

Selective serotonin reuptake inhibitors are considered the first line drug treatment because of their favorable side effects. Trazodone is a good choice to use at bedtime for depression and insomnia. Dopaminergic agents can be used for severe apathy.

who is most susceptible to developing Alzheimer's disease?

as individuals with a history of depression practically does with onset before age 60 have a 2.5 times greater risk of developing A.D.

Button nursing intervention that can be done to reduce the anxiety and patients with early stages of dementia?

encourage the patient to verbalize their feelings and fears associated with this loss.

What are the risk factors and taking benzodiazepines one of the benefits?

should not be used routinely or for prolonged periods due to risk of dependence. The benefits are that they are the least toxic and most effective.

What are examples of benzodiazepines?

Diazepam, chlordiazepoxide, alprazolam, lowers a pound, and oxazepam.

Why are barbiturates contraindicated for patients with anxiety and dementia?

Frequently induced confusion and paradoxical excitement in elderly individuals.

what are some nonpharmacological interventions America can do to assist with insomnia with patients with dementia?

make sure they wake up at the same time each morning and minimize daytime sleep; have them participate in regular physical exercise but no later than four hours before bedtime; make sure they have a proper diet and avoid alcohol caffeine and nicotine and have them go to sleep at the same time each night.

What are the risk of getting them sedative hypnotic medications?

Most elderly patients are Artie taken many medications the risk for drug drug interactions is high. That is why pharmacological treatment for insomnia should be considered only after nonpharmacological strategies have failed.

Examples of sedative hypnotic medications

benzodiazepines are useful for short period time only. These include flurazepam, temazepam, and triazolam. Enter non-benzodiazepine sedative hypnotics include zolpidem, zaleplon, eszopiclone, ramelteon. Antidepressants include trazodone and mirtazapine.

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