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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

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Organic mental disorders

Organic Mental Disorders

Elisa A. Mancuso RNC, MS, FNS

Professor


Omd delirium
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
Delirium Etiology

General Medical Conditions

UTI URI CHF (Older acutely ill)

Systemic Disturbances

Fluid/Electrolyte imbalance

Thiamine deficiency

Exogenous Substances

Heavy metals- Lead (Pb) Mercury (Hg)

↑↑ Coke Heroin Marijuana ETOH

Medications

Benzodiazepenes Sedatives/Hypnotics

Analgesics Anticonvulsants Diuretics

Neuroleptics Antihypertensives Digoxin

Resolve underlying cause & condition improves!


Omd syndromes
OMD Syndromes

Amnesic Disorders:

Wernicke or Korsakoff

Chronic ETOH ingestion

↓ Nutrition = Thiamine (B1) deficiency

Symptoms

Confusion

Disorientation

↑ Distractibility

Impaired short & long term memory


Omd syndromes1
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
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
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
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 phases1
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 phases2
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
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 Affect

Concentration Memory Coordination Abstract Thinking

Judgment Sensory Perception


Nursing interventions1
Nursing Interventions

PALMER

Perception

Attention Span

Language

Memory

Emotional Control

Reasoning & Judgment


Nursing interventions2
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 interventions3
Nursing Interventions

Psychological Support

Supportive touch

Promote interaction

Group activity

Reminiscence therapy

Life review

Stimulates remote memory

Promotes ↑self-esteem

Distraction

Music therapy


Nursing interventions4
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 interventions5
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
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


Medications1
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
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
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

ADL & Self-care training program


Multidisciplinary approach1
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


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