Chapter 19

Created by lsm 

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health and gero

Definition of Cognition (process)

acquiring
storing
sharing
using information

Components of cognitive function

language
thought
memory
executive function
judgment
attention
perception

cognitive impairment (CI)

-disturbances in cognitive functioning
disturbances:
ORIENTATION
PROBLEM SOLVING
PSYCHOMOTOR ABILITY
REACTION TIME
SOCIAL INTACTNESS
-memory
-attention
-concentration
-intelligence
-judgement
-learning ability
-perception

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

Fluid Intelligence

Biologically determined skills independent of learning or experience
also associated with flexibility in -->Thinking, inductive reasoning, abstract thinking and integration

Crystallized Intelligence

Composed of Knowledge and abilities (skills) acquired through education and LIFE
Measures of crystallized intelligence include:
-Verbal meaning ,
-word association,
-social judgment,
-number skills

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

immediate recall
short term memory (range from mins---> days)
remote aka long-term memory

Memory retrieval

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:
Memory impairment
Vision, hearing impairment
Cultural, cohort variations
Education levels
Low literacy skills

How to assess cognitive impairment?

Cognitive Assessment
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

-3 D's of cognitive impairment

Dementia
Delirium
Depression

Delirium May affect up to _____ % of hospitalized adults and _____% of older adults in intensive care units

42% hospitalized
87% older adults in ICU

Delirium is associated with ....

Associated with:
increased length of stay,
increased use of healthcare services post discharge, and
morbidity,
mortality, and
institutionalization,
independent of age and
comorbid illnesses

Delirium causes significant distress to ________ and ______

patient and family

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

True or False Changes in Cognitive functioning are part of the "normal" aspects of aging

false

risk factors for delirium

Acute illness
Infections
Medications
Invasive equipment
Metabolic disturbances
Dehydration
Alcohol or drug abuse
Sensory impairments
Unrelieved pain
Surgery
Hip fracture
Cognitive impairment

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 NEECHAM?

CONFUSION SCALE
DELIRIUM-SPECIFIC ASSESSMENT INSTRUMENT

What is CAM?
CAM-ICU?

CAM-
DELIRIUM-SPECIFIC ASSESSMENT INSTRUMENT
CAM-ICU---
DELIRIUM- SPECIFIC ASS. INSTRUMENT FOR INTENSIVE CARE POPULATION
ALSO GOOD FOR ......
CRITICALLY ILL
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 ______.

PREVENTION
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 .....

Interventions:
Prevention
Managing risk factors
HELP program
Family-HELP program
Delirium "doula"
sitters or constant observers (COs)
Pharmacological treatment
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
3 immobility
4 visual im0airments
5 hearing impairments
6 dehydration
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?

innovative approach
borrowed concept from maternity care
delirium doula
providing support
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:
Aphasia
Apraxia
Agnosia
Disturbances in executive functioning

TYPES OF DEMENTIA

Degenerative dementias
Alzheimer's disease (AD)
Parkinson dementia (PDD)
Dementia with Lewy bodies
Frontotemporal lobe dementia
Vascular cognitive impairment
Vascular dementia
Mixed primary neurodegenerative disease and vascular dementia
Other dementias
Creutzfeldt-Jakob disease
HIV-related dementia

Most common form of dementia?

Alzheimer's disease

6th leading cause of death?

Alzheimer's disease

3rd most expensive medical condition

Alzheimer's disease

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

What are the 2 types of AD?

early-onset dementia (EO-D)
late-onset dementia

Early onset dementia (EO-D)

rare
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

late-onset dementia

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
Psychosocial factors
History of brain injury

DIAGNOSIS OF AD ---3 STAGES

PRECLINICAL
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)
Amnestic MCI
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

Treatment
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)

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