Mental Health Nursing II NURS 2310

1. Mental Health Nursing IINURS 2310 Unit 15 Cognitive Impairment and Thought Disorders

2. Key Terms Psychosis = Disorganization of the personality, deterioration in social functioning, and loss of contact with or distortion of reality; may include hallucinations and/or delusions Hallucinations = False sensory perceptions not associated with real external stimuli affecting any or all of the five senses Illusions = Misinterpretations/misperceptions of real external stimuli Delusions = False personal beliefs not consistent with intelligence or culture; belief continues to exist in spite of proof to the contrary

3. Paranoia = Extreme suspiciousness of others and of their actions/perceived intentions Depersonalization = Feelings of unreality Anhedonia = Inability to experience pleasure Religiosity = Excessive demonstration of or obsession with religious ideas/behavior Magical thinking = Belief that one’s thoughts or behaviors can control certain situations/people Neologisms = Invented words that have symbolic meaning to self but are meaningless to others Echolalia = Repetition of words one hears in attempt to identify with the speaker

4. Echopraxia = Imitation of movements made by others in an attempt to identify with them Perseveration = Persistent repetition of the same word/idea in response to different questions or other prompts Looseness of associations = Shifting of ideas from one unrelated subject to another Word salad = Random arrangement of groups of words that lacks any logical connection Circumstantiality = Delay in reaching the point of communication due to unnecessary/tedious details; inability to track the discussion topic

5. Tangentiality = Inability to get to the point of communication; unrelated topics are introduced and original discussion is lost Clang associations = Word choice is determined by sound instead of meaning (i.e. rhyming) Mutism = Refusal or inability to speak Catatonia = A state of stupor (extreme psychomotor retardation) or excitement (extreme psychomotor agitation) that is usually associated with a psychotic disorder Waxy flexibility = Passive yielding of ones’ body to positioning/posturing by others

6. Cognitive Impairment

7. Delirium • Cognitive disturbance manifested by disorientation, agitation, memory impairment, and inability to reason or partake in goal-directed activity • Develops within several hours or days; onset may be more abrupt (i.e. following head injury or seizure) • May be caused by systemic illness, metabolic imbalance, ingestion of toxins, drug or alcohol overdose, withdrawal from drugs/alcohol or medication

8. Symptoms of Delirium • Rambling, incoherent speech • Extreme distractibility • Hallucinations and/or illusions • Sleep disturbances with vivid nightmares • Hyperactivity/hypervigilance or catatonic stupor • Emotional instability (irritability, murmuring, moaning, fleeing or lashing out) • Autonomic manifestations (tachycardia, sweating, dilated pupils)

9. Progression of Delirium • Brief in duration (1 week to 1 month) • Symptoms diminish within 3 days to 1 week of resolution of underlying cause (full recovery may take up to 2 weeks) • May transition into a permanent cognitive disorder (i.e. dementia) if left unresolved • CBC, BMP, chemistry panel used to diagnose underlying cause • Treated by determination/correction of underlying cause (i.e. fluid/electrolyte status corrections, treatment of hypoxia, anoxia, or diabetic problems)

10. Neurocognitive Disorder (NCD) • Previously termed dementia • Progressive decline in cognitive function due to damage or disease in the brain beyond what might be expected from normal aging • Develops slowly over several months or years • Progression is typically irreversible • Diagnosed by evaluation (i.e. mental status exam/MSE, CT scan, ruling out of other underlying causes of symptomology) • Treatment focused on symptom management • Categorized as primary or secondary NCD

11. Primary NCD • The neurocognitive disorder itself is the major sign of an organic brain disease that is not directly related to another organic illness • Alzheimer’s disease is the most common cause of primary NCD; vascular insufficiency (as in stroke) is another common cause Secondary NCD • Occurs as a result of a physical disease or injury (directly related to another condition) • Causes include HIV, cerebral trauma; substance abuse

12. Symptoms of NCD • Impairment in abstract thinking/judgment; lack of impulse control • Uninhibited/inappropriate behavior; disregard of social conduct; personality changes • Neglectful of personal appearance/hygiene • Apraxia (inability to carry out motor activities) • Aphasia (inability to express needs) • Irritability, mood instability, sudden outbursts • Unable to comprehend own limitations; at risk for accidents or wandering away from home

13. Stages of NCD related to Alzheimer’s • Stage 1 = no apparent symptoms • Stage 2 = forgetfulness • Stage 3 = mild cognitive decline (interference with work performance) • Stage 4 = mild-to-moderate cognitive decline; confusion (confabulation common) • Stage 5 = moderate cognitive decline; early NCD (begins to lose independence) • Stage 6 = moderate-to-severe cognitive decline; middle NCD (disorientation) • Stage 7 = severe cognitive decline; late NCD (bedfast, aphasic, and immobile)

14. Medications for Clients with NCD • Cholinesterase inhibitors • Treats cognitive impairment • Side effects: dizziness, headache, GI upset • Examples: tacrine (Cognex), donepezil (Aricept), and rivastigmine (Exelon) • Antipsychotic agents • Treats agitation, aggression, hallucinations, thought disturbances, and wandering • Side effects: headache, dizziness, drowsiness • Examples: risperidone (Risperdal), olanzapine (Zyprexa), quetiapine(Seroquel), and haloperidol (Haldol)

15. Antidepressants • Treats depression, depression-related insomnia • Side effects: headache, drowsiness/dizziness • trazodone (Desyrel), mirtazapine (Remeron) • Anxiolytics • Treats anxiety • Side effects: drowsiness/dizziness, GI upset • lorazepam (Ativan) • Sedative-hypnotics • Treats insomnia • Side effects: headache, drowsiness/dizziness • zolpidem (Ambien), eszopiclone (Lunesta)

16. Nursing Care for Clients with Cognitive Impairment

17. Promote client safety • remain with client at all times to monitor behavior and provide reorientation and assurance • maintain room in low level of stimuli • Frequently orient client to reality • use clocks and calendars with large numbers • allow client to have personal belongings • Preserve the dignity of the client • Help client’s family/primary caregivers to facilitate care • Assist in dealing with caregiver burnout

18. Keep explanations simple • use face-to-face interaction • speak slowly and do not shout • Discourage rumination of delusional thinking • talk about real events and real people • Monitor for medication side effects • Allow plenty of time for client to perform tasks • Follow usual routine as closely as possible with regard to ADLs • Provide guidance and support for independent actions by talking the client through the task one step at a time

19. Thought Disorders

20. Brief Psychotic Disorder • Sudden onset of psychotic symptoms that last at least 1 day but less than 1 month • May or may not be preceded by a severe psychosocial stressor • Full recovery to premorbid level of function Schizophreniform Disorder • Identical to schizophrenia with the exception of duration (symptoms last at least 1 month but less than 6 months) • Prognosis is good, with full recovery to premorbid level of function likely

21. Schizoaffective Disorder • Diagnosis of both schizophrenia and a mood disorder, such as MDD Delusional Disorder • Presence of one or more nonbizarre delusions that persist for at least 1 month • Hallucinations are not present or are not prominent • Behavior is not bizarre • Delusions may be erotomanic, grandiose, jealous, persecutory, or somatic in nature

22. Types of Delusional Disorder • Erotomanic = Belief that someone (usually famous) is in love with oneself • Grandiose = Irrational ideas regarding one’s own worth, talent, knowledge, or power • Jealous = Belief that one’s sexual partner is unfaithful in the absence of substantiation • Persecutory = Belief that one is being treated malevolently in some way • Somatic = Belief that one suffers from a physical defect, disorder, or disease (such as an internal parasite or infestation of insects in/on the skin)

23. Schizophrenia • Disturbance in thought processes, perception, and affect that results in severe deterioration of social/occupational functioning • Symptoms categorized as positive or negative • Positive symptoms = in excess of normal function • Hallucinations, delusions, disorganized behavior, disorganized thinking and speech • Good response to antipsychotic medications • Negative symptoms = deficit in normal function • Affective flattening, alogia (poverty of speech), avolition (inability to initiate goal-directed activity), apathy, anhedonia, social isolation • Poor response to treatment/medication

24. Phases of Schizophrenia • Phase I: Premorbid Phase • indifferent to social relationships • appear cold and aloof • does not always progress to schizophrenia • Phase II: Prodromal Phase • social withdrawal • peculiar or eccentric behavior • bizarre ideas • unusual perceptual experiences • neglectful of personal hygiene and grooming • lack of initiate, interests, or energy • phase may last for many years

25. Phase III: Schizophrenia • delusions and/or hallucinations • disorganized speech • disorganized or catatonic behavior • affective flattening • marked decrease in level of functioning • persists for at least 6 months • Phase IV: Residual Phase • usually follows active phase of the disease • flat affect and impairment in role functioning • residual impairment usually increases after each exacerbation with active disorder

26. Medication Management of Schizophrenia • Typical antipsychotic agents • Side effects: nausea, sedation, EPS • Examples: chlorpromazine (Thorazine), fluphenazine(Prolixin), and haloperidol (Haldol) • Atypical antipsychotic agents • Side effects: drowsiness, dizziness, constipation, dry mouth, headache, nausea/vomiting, EPS • Examples: quetiapine(Seroquel), olanzapine (Zyprexa), clozapine (Clozaril), ziprasidone(Geodon), aripiprazole (Abilify), risperidone(Risperdal), and paliperidone (Invega)

27. Communicating with Clients with Thought Disorder

28. Use nonconfrontational speech and mannerisms • Encourage communication and expression of feelings and fears • Decrease stimuli and offer quiet activity • Seek clarification of statements • Provide recognition for constructive self-care activities • Make adjustments in food preparation and service for patients with paranoia • Establish therapeutic rapport by listening, sharing observations, and accepting silence

29. Patient Education for Clients with Cognitive Impairment or Thought Disorder

30. Nature of the illness (causes, symptoms) • Management of the illness • ways to ensure client safety • how to maintain reality orientation • providing assistance with ADLs • nutritional information • difficult behaviors • medication administration • matters related to hygiene and toileting • Support services • financial/legal assistance • support groups and respite care

31. Nursing Process for Clients with Cognitive Impairment or Thought Disorder

32. Assessment • information gathered from a number of sources because client is likely to be a poor historian • Diagnosis • disturbed thought processes R/T delusions (or concrete thinking or paranoia) AEB bizarre statements and behaviors • disturbed sensory perception R/T hallucinations (or illusions) AEB inability to tolerate group therapy, talking to self, or looking for or at something that is not there • self-care deficit R/T withdrawal and loss of motivation and judgment AEB poor hygiene, poor grooming, and avoiding others

33. Planning • development of the nursing care plan • Intervention • rapport building • limit-setting • communicating expectations • client/family education • Evaluation • focus is on short-term goals as opposed to long-term goals • resolution of identified problems is unrealistic • outcomes must be measured in terms of slowing down the process rather than stopping or curing the problem