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Elder psych 2

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trinaha's version from 2017-07-13 20:16

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• DEMENTIA Definitionsyndrome of acquired, persistent intellectual impairment with compromised function in multiple spheres of mental activity, such as memory, language, visual spatial skills, emotion or personality, and cognition
• DEMENTIA ClassificationsPrimary - dementia is the major sign of some organic brain disease i.e. Alzheimer’s Disease. Secondary - dementia caused by or related to, another disease or condition, i.e. HIV disease or a cerebral trauma
• DEMENTIA: SYMPTOMSImpairment in abstract thinking, judgment, and impulse control, Disregard for the conventional rules of social conduct, Neglect of personal appearance and hygiene, Language may or may not be affected, Personality change is common, Gradual onset (usually), Slow chronic course (usually)
• DEMENTIA: TYPES- Dementia of the Alzheimer’s Type (DAT) – most common
• DEMENTIA: TYPES Vascular Dementia (VD)Cause – significant cerebrovascular disease – interruption of blood flow to brain, Second most common form of dementia, More abrupt onset, Highly variable course, More common in men than in women
• DEMENTIA: TYPES Dementia due to HIVSecondary dementia, Cause – infection with HIV-1, Rates have declined since antiretroviral therapy, Dementia due to Head Trauma, Amnesia common neurobehavioral symptom – permanence may persist, Repeated head trauma such as from boxing
• DEMENTIA: TYPES Dementia due to Lewy Body DiseaseClinical course fairly similar to DAT- Progresses more rapidly, Irreversible, Earlier appearance of visual hallucinations & parkinsonian features. Presence of Lewy bodies (eosinophilic inclusion bodies) in cerebral cortex and brainstem. Highly sensitive to EPS effects of antipsychotic medications. May account for 25% of all dementia cases
• DEMENTIA: TYPES Dementia due to Parkinson’s DiseaseSeen in as many as 60% of patients with Parkinson’s disease. Loss of nerve cells in substantia nigra – diminished dopamine activity. May resemble Alzheimer’s Disease
• DEMENTIA: TYPES Dementia due to Huntington’s DiseaseDisease transmitted as Mendelian dominant gene. Damage in basal ganglia and cerebral cortex. Symptom onset – between 30 & 50 years old. Gradual decline into dementia and ataxia
• DEMENTIA: TYPES Dementia due to Pick’s DiseaseCause unknown but genetic factor seems to be involved. Clinical picture similar to Alzheimer’s Disease with one exception. Initial symptom usually personality change. Brain atrophy more focused in frontal and temporal lobes
• DEMENTIA: TYPES Dementia due to Creutzfeldt-Jakob DiseaseUncommon neurodegenerative disease, Cause – slow virus or prion, 5-15% have genetic component, Typical clinical presentation, Extremely rapid clinical course, Progressive deterioration & death within 2 years, Symptoms typically occur between 40-50 but may develop at any adult age
• Dementia due to Other General Medical Conditions. CausesEndocrine conditions such as hypoglycemia or hypothyroidism, pulmonary disease, hepatic or renal failure, cardiopulmonary insufficiency, fluid & electrolyte imbalances, nutritional deficiencies, frontal or temporal lobe lesions, CNS or systemic infections, uncontrolled epilepsy, & other neurological conditions
• DEMENTIA: TYPES Substance-induced Persisting DementiaEvidence must exist from history, physical examination, or lab findings that show causes related to persisting effects of substance use. Dementia persists long after effects of substance intoxication or substance withdrawal have subsided
• DEMENTIA: TYPES Dementia due to Multiple EtiologiesSymptoms of dementia attributed to more than one cause
• DEMENTIA of the ALZHEIMER’S TYPE (DAT)About 50-60% of all cases of dementia. Progresses by stages (7 stages). Stage 1. No apparent symptoms Stage 2. Forgetfulness Stage 3. Mild cognitive decline Stage 4. Mild-to-moderate cognitive decline; confusion Stage 5. Moderate cognitive decline; early dementia Stage 6. Moderate-to-severe cognitive decline; middle dementia Stage 7. Severe cognitive decline; late dementia
• DEMENTIA of the ALZHEIMER’S TYPE (DAT) Etiologies - several theories proposed. Acetylcholine alterations – decreased production, Plaques and Tangles. New research – two-molecule aggregate of beta-amyloid protein fragment may initiate the disease – Shankar & Selkoe, 2008. Head trauma. Genetic factors - familial pattern – early-onset cases, link between DAT & altered or mutated genes. Mutated genes- TREM2, ApoE4
• DEMENTIA of the ALZHEIMER’S TYPE (DAT) diagnosisDefinitive diagnosis: biopsy or autopsy, CT or MRI of brain may detect changes, Rule out all other causes of dementia
• NATURE OF ALZHEIMER’S DISEASE Neurodegenerative Disorderdegradation of gray matter in cortex of brain, nerve cells involved in memory & cognition, caused by accumulation of destructive lesions, NEURITIC PLAQUES – build up between nerve cells – contain deposits of beta-amyloid fibers, NEUROFIBRILLARY TANGLES - paired helical filaments – form inside dying cells, GRANULOVASCULAR DEGENERATION
• NATURE OF ALZHEIMER’S DISEASE Chemical Changes in the BrainAcetylcholine reduced, Decreased acetyltransferase in hippocampus & cortex, Norepinephrine, serotonin, dopamine, & glutamate levels implicated
• SUNDOWNER’S SYNDROMEA phase of confusion & irritation. Seen at night or late in the day. Increased confusion, irritation, & signs of anxiety. Probably caused by general mental & physical tiredness which interferes with the ability to process further information
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• PHARMACOLOGICAL INTERVENTIONS FOR DAT
Question Answer
• Cholinesterase inhibitors– enhance cognitive functioning
• Tacrine (Cognex) –Cholinesterase inhibitors, rarely used RT possible liver damage
• Donepezil (Aricept) –Cholinesterase inhibitors, approved for all stages of DAT
• Galantamine (Reminyl) –Cholinesterase inhibitors, approved for mild/moderate DAT
• Rivastigmine (Exelon) –Cholinesterase inhibitors approved for mild/moderate DAT
• Glutamate blocker enhance cognitive functioning
• Memantine (Namenda) –Glutamate blocker, for moderate to severe DAT
• Antipsychotic agents –for agitation, aggression, hallucinations, thought disturbances, and wandering
• Risperidone (Risperdal) Antipsychotic agents, Atypical
• Olanzapine (Zyprexa) -Antipsychotic agents, Atypical
• Quetiapine (Seroquel) -Antipsychotic agents, Atypical
• Haloperidol (Haldol) –Antipsychotic agents, typical first generation antipsychotic
• Antidepressant agents – for depression
• Sertraline (Zoloft) -Antidepressant agents, SSRI
• Paroxetine (Paxil) -Antidepressant agents, SSRI
• Nortriptyline (Pamelor) -Antidepressant agents ,TCA
• PHARMACOLOGICAL INTERVENTIONS FOR DATAntianxiety agents – benzodiazepine medications, Sedative-hypnotic agents, Ginkgo biloba – not currently listed as a treatment, NSAIDs – NOT reducing AD risk according to recent clinical trial, Vitamin E – combats oxidation process – not currently approved
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Question Answer
• AMNESTIC DISORDERSCharacterized by inability to learn new information (short-term memory deficit) despite normal attention, and an inability to recall previously learned information (long-term memory deficit). Onset: may be acute or insidious. Duration and course variable (depending on underlying pathological process)
• AMNESTIC DISORDERS: Additional SymptomsDisorientation to place and time (rarely to self), Confabulation - the creation of imaginary events to fill in memory gaps, Denial that a problem exists, or acknowledgement that a problem exists, but with a lack of concern, Apathy, lack of initiative, and emotional blandness, No impairment in abstract thinking or judgment, No personality change
• Amnestic disorders due to a general medical condition. Associated medical conditionsHead trauma, Cerebrovascular disease, Cerebral neoplastic disease, Cerebral anoxia, Herpes simplex encephalitis, Poorly controlled insulin-dependent diabetes, Surgical intervention to the brain
• Transient amnestic syndromes can occur fromCerebrovascular disease, Cardiac arrhythmias, Severe migraine headache, Thyroid disorders, Epileptic seizures, Electroconvulsive therapy, Drug overdose
• Substance-induced persisting amnestic disorder R/T poisoning effect of the use of the followingAlcohol, Sedatives, hypnotics, and anxiolytics, Medications- anticonvulsants , intrathecal methotrexate, Toxins- lead, mercury, carbon monoxide, insecticides, solvents)
• INTERVENTIONS FOR DELIRIUM, DEMENTIA, & AMNESTIC D/OsAssessment, Client safety - no restraints if possible, Intervene to eliminate the cause(s) if possible, Eliminate overwhelming environmental, intrapersonal, or interpersonal stressors, Provide structure and routine to provide pattern and meaning, Develop interpersonal relationships that promote trust, Communication techniques, Eye contact, one-step commands, clear, succinct, Evaluate interventions
• Caregiver EducationEstablish alliance with caregivers and other family members, Teach about the disease process, Be open to learning about the psychosocial realities of the home care setting, Encourage family caregivers to seek legal advice as needed, Provide information about effective communication skills, Behavioral strategies, Environmental modifications, Provide information about outside assistance respite services, support groups, transportation information, nursing homes
• DEPRESSIONLess common in older adults than in younger adults, Most common functional psychiatric disorder among older adults, Often unrecognized in the older adult, More common in older women, Elderly white men have high rate of successful suicide - more likely to use lethal means, Suicide rates in nonwhite men are rising
• CAUSES OF DEPRESSION IN OLDER ADULTSOther mental illnesses, Loss, Physical illness, Medication, Drugs, & Substance Abuse, Failure to thrive, Loneliness & isolation, Care giving roles
• DEPRESSION: INTERVENTIONSEvaluate your feelings about caring for depressed clients, Effective interpersonal relationship- Offer hope, Take time - speech patterns, movements, & thought processes may be slowed, Acknowledge feelings, Demonstrate respect, Plan successes for the client, Serve as a role model for behaviors, Involve the client’s family, Use an interdisciplinary approach
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Question Answer
• Manifestations Physical Abusebruises, welts, lacerations, burns, punctures, evidence of hair pulling, & skeletal dislocations and fractures
• Manifestations PsychologicalSymptoms associated with depression, withdrawal, anxiety, sleep disorders, and increased confusion or agitation
• Manifestations Neglectconsistent hunger, poor hygiene, inappropriate dress, consistent lack of supervision, consistent fatigue or listlessness, unattended physical problems or medical needs, or abandonment
• Manifestations Sexual Abuse (suspected)pain or itching in genital area, bruises or bleeding in external genitalia, vaginal, anal areas, or breasts, unexplained sexually transmitted disease
• Manifestations Financial Abuseobvious disparity between assets and satisfactory living conditions, elderly person complains of sudden lack of sufficient funds for daily living expenses, Signatures on checks that do not match the older adult’s signature
• Nursing Home Reform Act of 1987The right of protection against Medicaid discrimination. The right to participate in health care decisions and to give or withhold informed consent for particular interventions. The right to safeguards to reduce inappropriate use of physical and chemical restraints. The right for provisions to ensure proper transfers or discharges. The right to full access to a personal physician, long-term care ombudsman, and other advocates. The right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. The right to be free from physical restraints or psychoactive drugs administered for the purpose of discipline or convenience
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