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Neurology

Neurology. Alzheimer's Disease (and other things we need to cover). Alzheimer’s Disease. AKA AD Primary degenerative dementia Senile dementia Organic Brain Syndrome Old timers disease. Pathophysiology. Dementia Characterized by an uneven, downward decline in mental function.

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Neurology

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  1. Neurology Alzheimer's Disease (and other things we need to cover)

  2. Alzheimer’s Disease AKA • AD • Primary degenerative dementia • Senile dementia • Organic Brain Syndrome • Old timers disease

  3. Pathophysiology • Dementia • Characterized by an uneven, downward decline in mental function

  4. Pathophysiology Alzheimer’s • Progressive • Irreversible • Degenerative neurologic disease • Begins insidiously • Characterized by • Gradual losses of cognitive function • Disturbances in behavior & affect

  5. Pathophysiology • Physical changes o the cerebral cortex are visible under a microscope • Neurofibriallary tangles • Neuritic plaque • Decrease in brain size

  6. Pathophysiology • First affected • Cells that use Acetylcholine • Left side • Parietal & temporal lobes

  7. Etiology • Familial tendencies • Risk factor • Age • Men vs. women? • Equal

  8. Clinical Manifestations • Slowly progressive • Subtle • Age • 85+

  9. Clinical Manifestations • 3 categories of Changes characteristic of dementia – • Cognitive • Functional • Behavioral

  10. Clinical Manifestations Stage 1- Early • Cognitive • Forgetful • Subtle mild memory loss • i attention span • Recent memory  remote memory

  11. Clinical Manifestations • Stage 1 – early • Functional • Small difficulty in work (able to hide it) • Mild anomia (cannot name objects) • No motor deficits

  12. Clinical Manifestations Stage 1 – early • Behavioral • Depression • Little interest in immediate surroundings • Lack of spontaneity • Social behavior intact • Hide cognitive deficit

  13. Stage 2 – Middle • Cognitive • Obvious short term memory lapses • Disoriented to time • Impaired judgment • Frequent loss of objects • Repeat the same story • Ability to think abstractly disappears

  14. Stage 2 – middle • Functional • Hesitancy in verbal responses • Confabulation • Gets lost in familiar places • i ability to handle money, use phone

  15. Stage 2 – middle • Behavior • May try to hide memory problems • Impulsive behavior • Hyperactive

  16. Stage 3 – Late • Cognitive • Disintegration of personality • Disorientation to person, place and time • Confused • Agitation • Irritability • Paranoid delusions

  17. Stage 3 – Late • Functional • May forget to use objects correctly • Dysarthria

  18. Stage 3 – late • Behavioral • Wandering • Restlessness • Pacing • Agitation • Disengages from activities & relationships • Combative

  19. Stage 3 – late • Behavioral • Sundowning • Confused & restless after dark • Want to go home • Less coping ability

  20. Stage 4 – End Stage • Cognitive • Terminal stage • Severe physical and mental deterioration • No recognition of family or self

  21. Stage 4 – End stage • Functional • Need total care for ADL’s • Incontinent • Loss of ability to communicate • Loss of all voluntary activity • Swallowing problems

  22. Review: Stage 1 (mild) • Confusion and memory loss • Disorientation to time and place • Difficulty in performing routine tasks • Change in personality and judgment

  23. Review: Stage 2 (moderate) • Difficulty performing ADL’s • Anxiety • Suspiciousness • Agitation • Wandering • Pacing • Sleep disturbances • Difficulty recognizing family members

  24. Review: Stage 3 (Severe) • Loss of speech • Loss of appetite • Weight loss • Loss of B&B control • Total dependence on caregiver

  25. Assessment & Diagnosis • Hx & PE • Neuro tests • Autopsy • MRI • Apparent changes • Cognitive assessment scale • Functional dementia scale • Mini-Mental Status Exam • Disorientation • Cognitive impairment

  26. Medical Management • Exercise • i anxiety & restlessness • PT • Diet • Well balanced • Hydration

  27. Medical Management Rx • Cognex (tacrine Hydrochloride) • Enhances acetylcholine uptake in the brain • S/E/ • Liver toxicity • Aricept (donepezil) • cholinesterase inhibitor • Improves mental function • by increasing the amount acetylcholine

  28. Nursing Management Priority Nrs Dx. • Risk of injury • Anxiety • Communication • ADL • Alt. Nutrition

  29. Nursing Management • Sundowning • DC all non-essential meds • Check for pain • Light on • Exercise daily • No caffeine • Anti-depressants • Having the patient sleep in a chair is better than no sleep at all

  30. Nursing Management Supporting Cognitive function • Calm, predictable environment • Limit environmental stimuli • Regular routine • Quiet pleasant manner of speaking • Clear & simple explanations

  31. Nursing Management Supporting cognitive function • Memory aids • Colanders • Pictures • Stop signs • Clocks • Instruction signs/notes • Pill organizer

  32. Nursing Management Promoting Physical safety • Move around freely • Remove hazards • Nightlights • Medications • Food • Smoking with supervision • Restraints? • NO!

  33. Nursing Management Promoting Physical safety • Secure doors • Wear ID • Care at night • Shoes

  34. A client has been recently admitted with a medical diagnosis of dementia, Alzheimer’s type. When obtaining an assessment, the nurse should remember for safety purposes to ascertain what crucial information? • Sleep patterns and behavior • Skin turgor • The degree of memory impairment • The level of distractibility

  35. Nursing Management Reducing anxiety & agitation • Uncluttered • Familiar • Low stimuli • Calm & hurried care • Music • Stroking • Rocking • Distraction

  36. Nursing Management Reducing anxiety • Validation therapy • Enter their reality • Ask questions • Feelings • Distract • Reality orientation • Structure activities • Avoid triggers

  37. Nursing Management Improving communication • Unhurried • i noise • i distractions • Clear & easy • List • Simple written • Non-verbal

  38. Nursing Management Promoting independence • Highest level of function • Clothing • Simple steps • Personal dignity • Choices • Dangerous activities

  39. Nursing Management Promoting Socialization & intimacy • Visits Good • Short • Non-stress • 1 or 2 at a time • Simple activities • Walking

  40. Nursing Management • Exercise • Pet therapy • Intimacy????

  41. Nursing Management Adequate nutrition • Calm & simple • Familiar foods • Look appetizing • Taste good • 1 food at a time • Small pieces

  42. Nursing Management • Finger foods • Food on the run • Watch hot food • Bibs? • Dental care

  43. Nursing Management Balance activity and Rest • Wandering • Assess sleep pattern • Day time • Exercise • Regular patterns • Limit long naps

  44. Nursing Management • Sleep aid • Warm milk • Music • Back rub • Warm bath • Tea

  45. Complications • Malnutrition • Dehydration • Pneumonia • Pain • Grimacing • Restlessness • Flexed position

  46. Small Group Questions • Damage to the brain in a patient with Alzheimer’s Disease occurs where? • What memory is lost first in a patient with Alzheimer’s disease? • Which neurotransmitter is associated with memory • Given three nursing intervention for a patient with Alzheimer’s who is losing weight?

  47. A patient is confused and wandering. What intervention will best maintain safety? • What about night time wandering? • A patient with Alzheimer’s occasionally she screams and moans and annoys the other patients by repeating the same word over and over. The best approach for a solution to this behavior is for the nurses to do what? • What medications are being used to treat AD?

  48. What activities are good for a patient who is confused or has short attention span? • What are the priority nursing diagnosis for someone with AD? • Give an example of confabulation • What is the biggest risk factor for AD? • When are AD patient most agitated?

  49. Strategies to Minimize or Prevent Sundowning • Make sure sundowning is not the result of physical illness or medication. • Caregivers need to be flexible in their approach and in their expectations. • Avoid caffeine drinks in the afternoon and evening. • Have non-glare lighting. • Be soothing and try to be undemanding. Try to make the person with Alzheimer's feel safe and secure.

  50. Make sure the person's physical needs are met, i.e. that they are not hungry, thirsty, or constipated. • Avoid too many naps during the day. • Soothing music may help relax them. • Provide stimulating activities in the day without exhausting the person. • Remember that a person with Alzheimer's does not have control over their behavior

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