Components of cognitive function
cognitive impairment (CI)
-disturbances in cognitive functioning
Cognitive Reserve (CR)
Ability to compensate for age-related changes
-"Use it or lose it" applies to cognitive function as well as physical health
-Based on concept of neuroplasticity
-Maximizing cognitive reserve
Engage in cognitive, sensory, and motor activities
Engage in meaningful social interaction regularly
---CR affects enables brain to sustain normal function even with significant disease or injury
Biologically determined skills independent of learning or experience
also associated with flexibility in -->Thinking, inductive reasoning, abstract thinking and integration
Composed of Knowledge and abilities (skills) acquired through education and LIFE
Measures of crystallized intelligence include:
-Verbal meaning ,
Classic Aging Pattern
older people perform more poorly on performance scales (Fluid intelligence), but scores on verbal scales (Crystallized Intelligence) remain stable
fluid intelligence decreases while crystallized intelligence remains stable
Related to speed of cognitive processing and slower reaction time
also affect performance
3 components characterize memory
short term memory (range from mins---> days)
remote aka long-term memory
Recall of newly encountered information decreases with age; memory declines noted for complex tasks and strategies
Age-associated memory impairment (AAMI)
normal memory loss
Age-associated memory impairment (AAMI)
normal memory loss
cognitive stimulation and memory training may be helpful for cognitively intact older adults and for those with cognitive impairment
Myths about aging and the brain
Myth:There is no pint in trying to teach older adults anything since "you cant teach an old dog new tricks"
Whats the Fact????
Basic intelligence remains unchanged with age
Minimize the barriers so that continued learning can occur more easily
barriers to learning:
Vision, hearing impairment
Cultural, cohort variations
Low literacy skills
How to assess cognitive impairment?
Evaluation of cognition requires formal focused assessment
Complete assessment, including laboratory workup, should be performed to rule out any medical causes of cognitive impairment
-3 D's of cognitive impairment
Delirium May affect up to _____ % of hospitalized adults and _____% of older adults in intensive care units
87% older adults in ICU
Delirium is associated with ....
increased length of stay,
increased use of healthcare services post discharge, and
independent of age and
Delirium is considered a medical emergency when what changes? Why is Delirium usually missed by health care professionals?
Cognitive changes in older people often labeled as confusion by nurses and physicians; frequently accepted as part of normal aging
Delay in treatment contributes to negative outcomes with delirium
risk factors for delirium
Alcohol or drug abuse
What assessment tools do you use to test for delirium? When should you use these ass tools?
MMSE-2 (Mini-Mental State Examination)
CAM (Confusion Assessment Method)
CAM-ICU (Confusion Assessment Method intensive care unit)
NEECHAM Confusion Scale
-----SHOULD BE CONDUCTED ON ADMISSION TO HOSPITAL
-THOUGHOUT HOSPITALIZATION FOR ALL AT RISK FOR DELIRIUM PATIENTS
-ALL PATIENTS WHO EXHIBIT SIGNS AND SYMPTOMS OF DELIRIUM
-OR DEVELOP ADDITIONAL RISK FACTORS
What is MMSE-2?
general test of cognitive status
helps identify mental status impairment
standardized method to assess mental status
use as baseline from which to track changes
NOT ADEQUATE FOR DIAGNOSING DELIRIUM
What is CAM?
DELIRIUM-SPECIFIC ASSESSMENT INSTRUMENT
DELIRIUM- SPECIFIC ASS. INSTRUMENT FOR INTENSIVE CARE POPULATION
ALSO GOOD FOR ......
NONVERBAL PATIENTS (who are on mechanical ventilation)
CAM VERY USEFUL NOW PART OF THE DAILY FLOW SHEET
Documentation should focus on ________ ______ of altered mental status rather than "__________"
Why should we do this?
Documentation should focus on SPECIFIC INDICATORS of altered mental status rather than "CONFUSED"
Will lead to more appropriate prevention, detection, and treatment to prevent negative outcomes
INTERVENTION BEGINS WITH ______.
an awareness and IDENTIFICATION of the risk factors for delirium and a formal assessment of mental status are the 1st line INTERVENTIONS FOR PREVENTION.
Interventions consist of .....
Managing risk factors
sitters or constant observers (COs)
Minimize side effects
what is the intervention HELP PROGRAM for? What is it?
HELP = HOSPITAL ELDER LIFE PROGRAM
WELL RESEARCH MULTIDISCIPLINARY PROGRAM OF DELIRIUM PREVENTION
-program of delirium prevention in the acute care setting
-focuses on managing six risk factors for delirium
1 cognitive impairment
2 sleep deprivation
4 visual im0airments
5 hearing impairments
USED IN OVER 60 HOSPITALS AND INTERNATIONALLY
40% REDUCTION IN INCIDENCE OF DELIRIUM
67% REDUCTION IN RATES OF FUNCTIONAL DECLINE
SAVES $$$ HOSPITALS & LONG TERM CARE FACILITIES
What is the intervention Family-HELP for?
an adaptation and extension of the original HELP program
-trains family caregivers in selected protocols
(orientation, therapeutic activities, vision and hearing)
interventions in the HELP program are
offering herbal tea or warm milk instead of sleeping meds
keeping the ward quiet at night by using vibrating beepers instead of paging systems, using silent pill crushers, removing catheters and other devices that hamper movement as soon as possible, encouraging mobilization, assessing and mananging pain, correcting hearing and vision deficits. etc etc pg 371
Delirium intervention "doula" is what?
borrowed concept from maternity care
adjusting environment to meet patient behavior needs
assisting patient to get help when needed
Treatment of Delirium
Pharmacological interventions to treat symptoms of delirium
-necessary if patients are in danger of harming themselves or others
-or if nonpharmacological interventions are not effective
STUDIES HAVE SUGGESTED THAT USE OF DEMEDETOMIDINE AS A SEDATIVE OR ANALGESIC MAY REDUCE THE INCIDENCE OR DURATION OF DELIRIUM
---ANTIPSYCHOTICS FOR TREATMENT DEMONSTRATE SIMILAR RATES OF EFFICACY TO HALOPERIDOL FOR THE TREATMENT OF DELIRIUM AND HAVE --LOWER RATE-- AND --------SIDE EFFECTS --
Def of Dementia?
Dementia is an IRREVERSIBLE STATE that PROGRESSES OVER YEARS and causes MEMORY IMPAIRMENT and loss of IADLS
Clinical features of syndrome of dementia include at least one of the following:
Disturbances in executive functioning
TYPES OF DEMENTIA
Alzheimer's disease (AD)
Parkinson dementia (PDD)
Dementia with Lewy bodies
Frontotemporal lobe dementia
Vascular cognitive impairment
Mixed primary neurodegenerative disease and vascular dementia
What causes Alzheimer's disease?
Development of neurofibrillary tangles in brain consisting of protein tau and extracellular deposits of amyloid-β peptides
Loss of connections between nerve cells and death of these nerve cells
Early onset dementia (EO-D)
affecting 5% of people who have AD
develops b/w ages of 30-60
result from gene mutations on chromosomes 21,14, and 1 cause abnormal protein to be formed
genetic testing available for at-risk individuals
most cases of AD
develop after 60 years old
mutations of EO-D NOT INVOLVED ITS DIFFERENT
DOES NOT RUN IN FAMILIES
RELATED TO VARIATION IN ONE OR MORE GENES in COMBINATION with LIFESTYLE and ENVIRONMENTAL FACTORS
AD RESEACH FOCUSES ON
Focusing on interaction between risk-factor genes and lifestyle and environmental factors
Vascular risk factors
History of brain injury
DIAGNOSIS OF AD ---3 STAGES
STAGE 1- Preclinical (brain changes symptoms not evident)
Early cognitive decline before overt symptoms are present
STAGE 2-Mild Cognitive Impairment(change in COG from before and one or more cognitive domains, memory problems)
Multiple domain MCI
Single non-memory MCI
Approximately 12% of persons over age 70 have MCI and are 3-4 times more likely to develop AD
STAGE 3-Alzheimer's Dementia—most advanced stage(memory loss decline reasoning judgment word finding vision spatial issues)
Multiple deficits present
AD cultural differences
Differences in how individuals from racially and culturally diverse groups view dementia
Cultural beliefs about disease etiology and symptoms influence diagnosis, treatment, and help-seeking behaviors
Treatment of AD
Regular monitoring of disease progression and response to therapy
Caregivers also need ongoing education about the disease as well as assessment of own coping mechanisms and self-care behaviors
PHARMACOLOGICAL TREATMENT FOR AD
cholinesterase inhibitors (CIs) -block acetylcholinesterase
-medication therapy directed toward symptoms of AD and does not affect the neuronal decline (treats symptoms not disease)
-depression accompanies dementia (important to assess for depression and treat if present or IT WILL CAUSE EXCESS DISABILITY)