Cognitive Disorders ECT

1. Cognitive Disorders ECT Phyllis M. Connolly, PhD, RN, CS NURS 127A

2. Questions for consideration • What are the similarities and differences between delirium, dementia, and depression? • What is a catastropic reaction and what interventions are helpful? • What is a positive client outcome for altered thought processes? • What the indications for ECT?

3. Cognitive Impairments • 2.4 million Americans suffer from dementing illnesses • 7.3 million by 2040 • Alzheimer’s Disease • Dementias • Vascular--interruption of blood flow to brain • Parkinson’s--involves extrapyramidal • Diffuse Lewy Body Disease • Huntington’s Disease • Creutzfeldt-Jakob Disease • Alcoholic Dementia • TIA

4. Analgesics Codeine Meperidine Morphine Pentzcocine Indomethacin Antihistamines Dephenhydramine Hydroxyzine Antihypertensives Clonidine Hydralazine Methyldopa Propranolol Reserpine Antimicrobials Gentamicin Isoniazid Medications Causing or Contributing to Dementia or Delirium

5. Antiparkinsonism Amantadine Bromocriptine Carbidopa L-Dopa Cardiovascular Atorpine Digitalis Diuretics Lidocaine Hypoglycemics Insulin Sulfonyureas Psychotropics Benzodiazepines Lithium Tricyclics Haloperidol Thiothixene Chlorpromazine Barbituates Chloralhydrate Others Cimetidine Steroids Trihexyphenidyl & other anticholinergics Medications Causing or Contributing to Dementia or Delirium Cont.

6. Dementia • Constellation of symptoms resulting in impairment of short and long term memory • Onset slow or insidious • Progressive ends in death • Deterioration in judgment & abstract reasoning • Social & occupational functioning significantly affected • Most common cause Alzheimer’s

7. Four As of Alzheimer’s Disease • Amnesia--inability to learn new information or to recall previously learned information • Agnosia--failure to recognize or identify objects despite intact sensory function • Aphasia--language disturbance that manifest in both understanding & expressing the spoken word • Apraxia--inability to carry out motor activities despite intact motor function

8. Alzheimer’s: Etiology • Senile plaques & neurofibrillary tangles • Dystrophic neurites(thickened, swollen neuronal processes) • Abnormal amyloid deposits • Genetic--10-15% of cases • Toxin model--aluminum salts • Infectious agent model--virus • Cholinergic deficit model

9. Hallucinations Delusions Dysphoria & depression Fearfulness Repetitive purposeless acts Avoidance behavior Motor restlessness Apathy Verbal and physical aggression Resistance to interventions Hygiene Nutrition Safety Alzheimer’s Disease: Behavioral Symptoms

10. Stressors for Persons with Cognitive Impairments • Fatigue • Change of environment, routine or caregiver • Overwhelming or competing stimuli • Demands that exceed capacity to function • Physical stressors

11. Catastropic Reaction • Excessive distress exhibited by patients in situations that are confusing or frightening ex. Showering • Interventions • Remain calm • Remove patient from whatever is upsetting • Use distraction rather than confrontation

12. Impaired Cognitive Functioning • Key Elements of Care • Communication • Orientation • Structure • Stimulation • Safety

13. Altered Thought Processes • Client Outcomes • Demonstrates improved reality orientation • Responds coherently to simple requests • Follows simple directions • Interventions • Baseline mental status & functioning • Avoid making demands • Ask only one question & make only one request at a time • Provide a structured routine • Provide familiar objects • Avoid agreeing with confused thinking but DO NOT ARGUE--try to distract • Incorporate orientation cues from the environment • Keep environment simple & uncluttered

14. Delirium • Alterations in consciousness • Changes in cognition • Usually caused by medical condition or substance induced • Develop over short period of time • Treatable • 30% CCU environments, “CCU psychosis” • Disoriented • Disorganized thinking and speech • Altered perceptions: illusions, delusions & hallucinations • EEG changes • Neurological abnormalities

15. Delirium: Treatment • Identify & correct cause • anemia • dehydration • nutritional deficiencies • electrolyte imbalance • Monitor closely • Safety high priority • Control behavioral symptoms • Well lighted room, visible clock & calendar

16. Comparison Dementia, Delirium & Depression

17. Psychotherapeutic Management • Nurse-Patient Relationship • Psychopharmacology • Antipsychotics • Antidepressants • Antianxiety • Treatment of cognitive impairment • cholinergic enhancers • metabolic enhancers/vasodilators • Nootropic agents • Milieu management • Safety

18. Validation Therapy • Enter client’s world rather than force to relate to an external world which is no longer comprehensible • Increase the client’s sense of being understood by others • Reduces agitation and catastrophic reaction • quality of life Schober, Glod, Jones, 1998, p .252

19. Person wears identification bracelet Install special locks, safety devices on doors, stove & other potentially dangerous objects Check frequently for burns, bruises, or abrasions Assess for signs of abuse Only use restraints after other methods are ineffective--need MD order Look directly at person when speaking Identify yourself prior to interaction Use simple short phrases Ask specific rather than general questions Distract if asking same question repeatedly Assist in word finding Reassure that you intend to help Avoid arguing Convey patience and understanding Tips for Working with Persons with Dementia Promote Safety Communication

20. Tips for Dementia Care Cont. Decrease Confusion • Establish regular & predictable routine • Breakdown complex tasks into small simple steps • Consistent care by regular staff • Use large clock & calendar •  distraction & stimulation, avoid clutter & unnecessary objects • Post lists of daily activities • Person wear glasses & hearing aid • Avoid medications if possible • Check person frequently

21. Encourage regular exercise Ensure nutrition & hydration Assist with ADLs Assess frequently for physical pain, constipation, & discomfort Evaluate agitation and worsening behavior carefully Suggest day treatment for clients living at home Teach ways to manage uncooperative behavior Teach about causes and course of dementia Monitor & assess level of stress on the family Encourage use of social support to decrease caregiver stress Help families mourn the loss of their loved one Tips for Dementia Care Cont. Physical & Emotional Wellbeing Family Education Schober, Glod, Jones, 1998, p. 251

22. Modern ECT • Causes changes in monoamine neurotransmitter system • Electric current (70 - 150 volts) passes through the brain from .5 to 2 seconds • Seizure must last approximately 30 - 60 seconds for therapeutic value • ECT has cumulative effect, needing 220 - 250 seconds • Oximeter-monitor anesthetic to assure oxygenation • 2 - 3 times/week up to 6 - 12 treatments • May require periodic or maintenance ECT treatments

23. Disorders, Depressive Symptoms, & Conditions Responding to ECT

24. Preparation for ECT • Physical exam, blood ct., chemistry, urinalysis, & baseline memory abilities • Consent form “informed” • Eliminate benzodiazepines prior • Trained electrotherapist & anesthesiologist • Nursing responsibilities • NPO 8 hours prior to ECT • Atropine 1 hr. prior to treatment • Have patient urinate before treatment • Remove hairpins & dentures • Take vital signs • Reduce anxiety--be positive

25. Procedures During ECT • IV inserted • Electrodes placed on head • Bite-block inserted • Brevital IV • Anective IV, neuromuscular blocking agent • Ventilate 100% O2 • Electrical impulse 150 volts, 0.5 - 2 sec. • Monitor, heart rate, rhythm,BP, EEG

26. Nursing Care After ECT • Ventilate with 100% O2 until breathing unassisted • Monitor for respiratory problems • Reorient patient, time, place, person • If agitation may need benzodiazepine • Constant observation • Document all aspects of treatment • Monitor seizure activity, EEG

27. Very High Risk Recent myocardial infarction Recent CVA Intracranial mass lesion No absolutes High Risk Angina pectoris Congestive heart failure Extremely loose teeth Severe pulmonary disease Severe osteoporosis Major bone fractures Glaucoma Retinal detachment Thrombophlebitis Pregnancy Use of MAOIs Use of clozapine Contraindications for ECT

28. Disadvantages ECT • Temporary relief • Memory impairment, before and after ECT • Physiological effects • hypertension • arrhythmias • alterations in cardiac output • hemodynamic changes • increases in myocardial o2 consumption-ischemia • seizures

29. Other Somatic Therapies • Psychosurgery • Insulin-Coma • Metrazol-induced convulsions

30. Psychosurgery • Types • Cingulotomy • Subcaudate tractotomy • Capsulotomy • Outcomes, psychosurgeries • Suicide rate of 1300 persons dropped 15% to 1% post op • Contraindications • <20 yrs or >65 yrs • brain pathology, atrophy or tumor • personality disorders: borderline, paranoid, antisocial, histrionic • substance abuse • Adverse Reactions • Altered personality • infection, hemorrhage, hemiplegia,seizures, suicide, wt. gain

31. Phototherapy: Seasonal Affective Disorder • Light box • Phototherapy visor • Head-mounted light unit • Dawn stimulator