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Chapter 17: Neurocognitive Disorders Delirium:4 Types:1. Hyperactive with agitation and restlessness.2. Hypoactive with apathy and quietness.3. Mixed: Hyper & hypo.4. UnclassifiedMild NCDMajor “NCD” (Dementia)Short termSubtypes: NCD due to Alzheimer’s, Parkinson’s & Huntington’s disease.Subtypes: NCD due to Alzheimer’s, Parkinson’s & Huntington’s disease.ReversableAlzheimer’s: Neurodegenerative. Gradual impairment of cognitive function. Most common type.Alzheimer’s: Neurodegenerative. Gradual impairment of cognitive function. Most common type.Risks: Physiological, metabolic, cardio and respiratory changes or diseases, infections, surgery and substance abuse or withdrawal. Older age, multiple comorbidities, severity of disease, polypharmacy, intensive care units, surgery, aphasia, restraint use, or change in environment.Risks: Advanced age, prior head trauma, cardiovascular disease, lifestyle factors, and family history of AD. (Strong genetic link for AD).Risks: Advanced age, prior head trauma, cardiovascular disease, lifestyle factors, and family history of AD. (Strong genetic link for AD).Can also develop delirium.Screening Tools: CAM, NEECHAMScreening Tools: Functional Dementia Scale, MMSE, FAST, Global Deterioration Scale, Short Blessed Test.Onset: Short period of time.Manifestations: LOC usually altered & fluctuates. Restlessness, anxiety, motor agitation & fluctuating moods. Personality changes are rapid. Hallucinations & illusions. VS unstable. Considered medical emergency. Causes: Usually hospitalization of older adults. Medical conditions, and surgery often secondary to withdrawal from illegal substances or alcohol. Onset: Gradual over months to years.Manifestations: Impairments in memory, judgement, aphasia, agnosia, executive functioning, apraxia, impairments don’t change throughout the day. LOC usually unchanged. Restlessness and agitation are common. Sundowning. Personality change is gradual. VS are stable unless ill. Cause: Cog deficits aren’t related to another mental health disorder. Advance age as risk factor. Genetics, sedentary lifestyle, metabolic syndrome and diabetes mellitus. Subtypes caused by Alzheimer’s, TBI, Parkinson’s or other neurological systems.Outcome: Reversable if diagnosis and treatment of underlying cause are prompt.Outcome: Irreversible and Progressive.Medications:Can be underlying cause of delirium.Focus on treating underlying condition.Antipsychotics & antianxiety meds.Medications: Anticholinesterase Inhibitor Meds: Can improve ability to perform ADLs. Adverse effects: GI effects. Monitor for GI effects and fluid vol deficits. Promote fluid intake. Titrate and dosage to reduce GI effects. Bradycardia and syncope. Monitor pulse rate and screen for underlying disease. Contraindications: used with caution in patients with preexisting asthma or other obstructive pulm disorders. Interactions: NSAIDs, antihistamines, tricyclic antidepressants & conventional antipsychotics. Start med slow and gradually increase. Taper off of med when stopping. Can pt swallow tabs? At bedtime, with or without food. Rivastigmine with food. Memantine: For moderate to severe stages of AD. Used concurrently with cholinesterase inhibitor. With or without food. Monitor for common side effects.SSRIs, antipsychotics, but are last resorts because they carry so many adverse effects. Some vitamins and herbs but aren’t proven to help yet.Defense Mechanisms:Denial: It isn’t happening and refuse to believe it’s happening.Confabulation: Can’t remember so they make up stories unconsciously to protect themselves.Preservation: Can’t remember so they repeat the same thing over and over unconsciously to protect themselves.Diagnostic Procedures: (To rule out other pathologies!)Chest & head x-ray.EEGECGLiver studiesThyroid testingNeuroimaging.UABlood electrolytesFolate and B12 levelsVision & hearing testsLumbar punctureNursing Care:Best way to prevent: Minimize risk factors and recognize early.Perform self-assessment.Focus on protecting client.Provide safe and therapeutic environment.Watch for falls and wondering.Assign a room close to nurse’s station.Provide a room with low level of visual and auditory stimuli.Well lit environment and minimize contrasts and shadows.Sit in room with windows to help with orientation.Have client wear identification bracelet.Use restraints only if ordered.Caution with meds PRN for agitation and anxiety.Determine client’s risk for injury and ensure safety.Cognitive Support:Memory aids (clocks, calendars)Reorient as needed.Consistent daily routine.Consistent caregivers.Cover or remove mirrors.Encourage physical activity. Adequate lighting in bathroom at night.Physical Needs:Neuro statusIdentify disturbances.Skin integrity.VSMeasures to promote sleep.Level of comfort.Eyeglasses and hearing devices.Adequate food and drink.Education:Ensure safety and teach them how to adapt home environment.Will client wander out if the doors aren’t locked?Can client remember address and name?Does client harm others when allowed to wander in LTC facility?Remove rugs.Install strong locks.Lock water heater thermostat.Good lighting.Handrails.Matresses on floor.Remove clutter.Electrical cords to basements.Lock up cleaning supplies.Encourage family to seek legal council regarding wills and DPOA.Determine needs for client and family members.Review resources available to tell the patients.Support caregivers.Encourage family members to take care of themselves. ................
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