Organic Mental Disorders Elisa A. Mancuso RNC, MS, FNS Professor OMD Delirium Identified cerebral disease or dysfunction – Acute & fluctuating Altered neuronal pathways Impaired cognition – – – – Decision making Problem solving Interpreting environment Learning new information Disturbed consciousness – Disoriented to time & place – Illusions, hallucinations, anxiety, & ▲ sleep patterns Delirium Etiology – General Medical Conditions UTI URI CHF (Older acutely ill) – Systemic Disturbances Fluid/Electrolyte imbalance Thiamine deficiency – Exogenous Substances Heavy metals- Lead (Pb) ↑↑ Coke Heroin – Medications Benzodiazepenes Analgesics Neuroleptics Mercury (Hg) Marijuana ETOH Sedatives/Hypnotics Anticonvulsants Diuretics Antihypertensives Digoxin Resolve underlying cause & condition improves! OMD Syndromes Amnesic Disorders: Wernicke or Korsakoff – Chronic ETOH ingestion – ↓ Nutrition = Thiamine (B1) deficiency – Symptoms Confusion Disorientation ↑ Distractibility Impaired short & long term memory OMD Syndromes Senile Dementia – 6% people > age 65 or 30% > age 90 – Syndrome of acquired, persistent intellectual impairment – Etiology Cerebral hypoxia Intracranial tumors Hydrocephalus MS Hypertensive Encephalopathy – Symptoms Short-term memory deficit Aphasia Confabulation Blocking ↓ Abstract thinking Poor judgment & impulse control Disintegrating personality Alzheimer’s Degenerative Dementia – 70% of all dementia = 4 million people – Slow & insidious onset – Progressive & chronic deterioration 8-15 years from onset – Women 2x>men – Irreversible ACh deficiency =↓ neuron impulse ↑ Aluminum accumulation Altered immune system – ↑ Ab titers (Protein A-68) ↑ Beta Amyloid – Neuronal plaques Neurofibrillary tangles – Cortex atrophy Alzheimer’s Predisposing Factors Head trauma Genetic: Chromosome # 14 & 21 Vascular injury 2 to HTN or cerebral emboli Huntington’s Chorea Parkinsons Disease Pick’s Disease – Degeneration of frontal lobe Creutzfeldt-Jakob Disease – Infectious process Secondary to HIV Alzheimer’s Phases Phase I : Forgetfulness (1 year) – Short term memory loss (Absent minded) – Lose things & forget names of people – Pt aware & tries to compensate – Anxious & fearful regarding losing abilities – Frustrated Alzheimer’s Phases Phase II : Confusion (2-12 years) – Hyperorality – Tantrums & Wandering – Sundowning Afternoon Worsening: Agitation & Confusion – Difficulty concentrating yet denies problem Lost when driving ↓ Work performance Inability to learn new information or recall information – Perservation Verbalize same idea repeatedly – Agnosia Failure to identify objects Alzheimer’s Phases Phase III- Terminal Dementia (8 mos -2 years) – Severe & significant decline in functioning – ↓ Memory of major life events & family members – Regression – Poor impulse control ↑ Sexual behavior – Unable to do ADLs independently Incontinent – Delusions, Hallucinations, Anxiety – Aphasia, Agraphia & Apraxia – Final vegetative state Nursing Interventions Physical Exam – R/O any organic cause PET, CT, MRI – √ Neurofibrillary tangles & atrophy of cortex Hx of onset Family, friends & colleagues Assess Mental Status Orientation Concentration Coordination Judgment Affect Memory Abstract Thinking Sensory Perception Nursing Interventions PALMER – Perception – Attention Span – Language – Memory – Emotional Control – Reasoning & Judgment Nursing Interventions # 1 Patient Safety! – ID bracelet – Notify Police & local stores – Recent photo & all contact #s – Physical Environment Security system in home Childproof Consistent & uncluttered ↓ Stimulation Well lit & handrails Nursing Interventions Psychological Support – Supportive touch – Promote interaction Group activity – Reminiscence therapy Life review Stimulates remote memory Promotes ↑self-esteem – Distraction Music therapy Nursing Interventions ADLs – – – – – Allow Pt to make simple choices = ↑ control Break down tasks to short, simple steps = KISS Give verbal & visual cues Clear expectations Allow ample time to perform Velcro, elastic, large zippers & sneakers Exercise – ROM PT & daily walks – ↑ activity in day ↓ wandering @ night Nursing Interventions Nutrition – – – – – Keep mealtimes consistent Provide finger foods Balance diet with↑ calorie liguids Weigh weekly Use bowls & spoons Bibs & drop cloths Elimination – – – – √I&O ↓ Fluids @ bedtime Toilet @ regular intervals q 2h Incontinent products Medications Help delay or prevent worsening of symptoms Start low & go slow with dosages! Tacrine (Cognex) – Reversible Cholinesterase Inhibitor – Slows the natural breakdown of ACh = ↑ ACh – Slows progression of memory loss – SE Diarrhea Diaphoresis ↑ Urination & Salivation Hepatotoxicity Medications Donepezil (Aricept) – Slows the natural breakdown of ACh = ↑ Ach – Only effective on intact cholinergic neurons – SE Insomnia = ↑ Wandering HA Seizures Diarrhea N&V Atrial fibrillation Rivastigimine (Exelon) Galantamine (Reminyl) Symptomatic Management Anxiolytics Short term use to ↓ anxiety ↓ BuSpar best = ↓ cognitive & psychomotor SEs Antipsychotics ↓Agitation ↓ Aggression ↓ Hallucinations ↓ Paranoid thinking Zyprexia & Seroquel best = ↓ EPS Antidepressants ↑ Sleeping ↑ Thinking ↑ Memory ↑ Appetite TCA ¼ -1/2 dose – Amitriptyline (Elavil) Trazodone (Desyrel) Bupropion (Wellbutrin) SSRIs – No Fluoxetine (Prozac) inhibits liver enzymes & ↑ serum levels of other meds – Paroxetine (Paxil) Citalopram (Celexa) Anticonvulsants ↓ Impulsivity & aggression Valproic Acid (Depakote) & Carbamazapine (Tegretol) Multidisciplinary Approach Speech Therapist – Restore swallowing – Delay aphasia Physical Therapist – “Use it or lose it” – Retain strength & memory – Improve large & fine motor skills Occupational Therapist – Sensory & Brain stimulation Multidisciplinary Approach Social Worker – Individual & Group Therapy – Family Support Sandwich generation ↑ Caretaking demands & multiple roles Coping with feelings of personal loss Anticipatory Grieving Assistance from all relevant agencies Alzheimer's Association. – Community Resources Respite care Day Care Centers Residential Facilities Specialized Alzheimer’s units