DELIRIUM AND DEMENTIA

PSYCHIATRY

Definition
Delirium is an acute confusional state,usually happening suddenly within hours or days. Its as a result of various physical causes,including infection,an endocrine disorder,trauma and drug abuse. Some of the causes are CHF,UTI,Liver failure,electrolyte imbalances, use of psychotropics & anticholinergics (Benadryl,Elavil),alcohol withdrawal

Clinical features

Disturbance of consciousness

reduced ability to focus, sustain or shift attention

memory deficits, disorientation (for time, place and person), language disturbances misinterpretations, illusions and hallucinations (usually visual)

Cognitive impairment

Perceptual disturbances

Disturbance in sleep-wake cycle Altered psychomotor activity

increased or decreased)

Disorganized thinking with incoherence and delusions

Associated features

Emotional disturbances common

anxiety, depression, irritability, anger

Abnormal movements, tremor, autonomic signs Dysnomia(difficulty in naming objects), Dysgraphia(difficulty in writing)

Neurological signs uncommon

Disorders of higher cortical function

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 of underlying condition)

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 disturbancesmisinterpretations,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 the day. The history,physical examination or lab. tests show evidence of 1 or more specific organic factors related to he disturbance It cannot be accounted for any other non-organic mental

disorder(eg,agitation in mania)

NURSING DIAGNOSIS

Disturbed thought processes related to changes in 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) related to 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

Treatment

Specific measures
Identify and treat the underlying condition Thorough medical history, physical and neurological examination, lab tests

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 and usually goes away when the condition is treated

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PREVENTIONS

Avoid taking too many different types of drugs Recognize signs of delirium so treatment can be 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 an irreversible course in which the damage remains permanent
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ETIOLOGICAL FACTORS

1.Neurological diseases like Huntingtons chorea, multiple sclerosis and Parkinson's disease. 2.Cardiovascular disorders causing anoxia and brain damage e.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 15

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 -Impaired judgment -disturbances of higher cortical function like Aphasia-disorder of language Apraxia-inability to carry out motor activities despite intact comprehension and motor function Agnosia-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 mental disorder (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 significantly impaired 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 person cannot 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) 22

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 is abrupt 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 the brain.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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Understanding Alzheimer's
In 1906 Dr. Alois Alzheimer was first to describe Alzheimer's disease.

Since then millions of people have been diagnosed with the disease.

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What Is Alzheimer's
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
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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 syndrome
Confused , disoriented behaviour that becomes noticeable after the sun goes down and during the night

Wandering behavior
Restlessness and activity seeking behavior The stalking of old haunts, night wandering

Catastrophic reactions
Heightened anxiety occurring during interviewing or questioning 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 of genetics.

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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 all reported cases.
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MANAGEMENT OF DEMENTIA

1.Treatment is generally community focussed: The goal of

treatment 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 in maintaining the safety and functional abilities of the patient as long as possible. 3.Pharmacological therapy: For patients of DAT anticholinesterase 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 reduction and 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 as demonstrated by inattention and inability to complete ADLs Risk for injury related to cognitive impairment and wandering behavior Impaired social interaction related to cognitive impairment Risk for violence:Self directed or directed towards others due to suspicion and inability to recognize people or places. Altered Family process related to impact of cognitive deficits on traditional roles and functioning Caregiver role strain related to lack of support and level of care necessary for the patient. 34

NURSING INTERVENTION
To provide a quiet structured environment to increase consistency and promote feeling of security

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 of care Check for hazards in the environment (rugs on floor) make sure 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 enhance self esteem.

Provide occupational therapy, physical therapy and recreational therapy that the client enjoys. Maintain a flexible schedule: keep client from becoming bored and 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 and the other rooms. Large clock with oversized numbers and hands,appropriately placed. Large calendar indicating one day at a time with month day and 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, label rooms. 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 phone number) 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 or intellectual deterioration Result of a specific insult to the brain Anterograde memory loss- the patient cant remember events that occurred after the brain insult Retrograde memory loss- the patient cant remember events that occurred before the brain insult Confabulation is commonly used as a defense 42 mechanism.

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 impairment Short-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 course of 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 44

Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to nutrient deficiency Impaired adjustment related to memory loss Risk for injury related to inability to learn safety rules Compromised family coping related to poor 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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