Maryville NURS663 Exam 2 (SU22)

Phases of Grief · Shock and denial (days-weeks) acute anguish, lost patterns of conduct, resolution (months-year) · Denial, bargaining, depression, anger, acceptance · No real timeline, comes in waves Grief vs. MDD · Grief- Sx may meet syndromal criteria for MDD episode, but survivor rarely has morbid feelings of guilt, worthlessness, SI, or psychomotor retardation o Considers self bereaved o Dysphoria often triggered by thoughts or reminders of the deceased o Onset within 2 months of bereavement o Duration of depressive episode is less than 2 months o Functional impairment is transient and mild o No family or personal hx of depression o Predominant affect is emptiness and loss o Pain of grief accompanied with positive emotions and humor, self-esteem generally preserved MDD vs. Grief MDD o May consider self weak, defective, or bad o Dysphoria is often autonomous and independent of thoughts or reminders of the deceased o Onset at any time o Depression often becomes chronic, episodic, or intermittent o Clinically significant distress or impairment o Family or personal hx of depression o Persistent depressed mood and inability to anticipate happiness or pleasure o Pervasive unhappiness and misery, self-critical and pessimistic ruminations, feelings of worthlessness and self-loathing Persistent Complex Bereavement Disorder o Unshakeable grief that does not follow the general pattern of improvement over time, individuals continue to experience persistent and intense emotions or moods and unusual, severe symptoms that impair major areas of functioning, or that cause extreme distress o Persists for greater than 6 months after bereavement o Patients report loss of self-worth and sense of self, feel emotionally disconnected from others and do not wish to move on from bereavement, sometimes feeling that to do so would represent a betrayal of the deceased o At least one of the following: Intense and persistent yearning for the deceased -Frequent preoccupation with the deceased -Intense feelings of emptiness or loneliness -Recurrent thoughts that life is meaningless or unfair without the deceased -A frequent urge to join the deceased in death Delirium Vs. Dementia Delirium o 4A & 3C: disturbance in attention and awareness. o Abrupt/acute onset with altering severity throughout the day. o Cognitive disturbance, consequence of another medical condition or substance related. o Can’t be explained by neuro-cognitive dx or coma o More short-term memory than long term memory impaired o Orientation grossly disorganized o Prominent hallucinations o Poor attention o Judgment, social skills, and behavior are grossly impaired o Associated with acute illness, vital signs often abnormal, neuro exam may be abnormal Dementia vs. Delirium Dementia o More long-term memory impaired than short term o Attention less impaired o Orientation varies o Rare hallucinations o Judgment, social kills, and behavior are initially relatively intact o Onset usually insidious o Short term course varies, but stable o Chronic and progressive Normal signs of aging and memory performance o Everything tends to slow down as we age o Erikson: integrity vs despair. Central conflict is coping, maintaining self-esteem, reconciliation. o Complains about memory loss, but can provide detailed examples of forgetfulness o Occasionally searches for words o May have to pause for directions, but doesn't get lost in familiar places o Remembers recent important events, conversations not impaired o Interpersonal social skills not impaired Screening tools for neurocognitive disorders in the geriatric population Mini-mental status exam (MMSE) - Most widely used, cutoff >24 SLUMS exam -Effective at screening for executive function domain -HS education: score 27-30 normal. Scores 21-26 mild neurocognitive disorder, scores between 0-20 indicate dementia Mini-Cog -3 minute screening for cognitive impairment -Cut-off <3 for dementia screening Alzheimer's Disease o Cause: Abnormal deposits of proteins form amyloid plaques and tau tangles throughout the brain. o Short-term memory loss o Impaired executive function o Difficulty with ADLs o Time and spatial disorientation o Language impairment, personality changes o Memory deficit, aphasia, apraxia, agnosia o Severe: cannot communicate o Onset: mid 60s and above Vascular Dementia o Cause: conditions such as blood clots disrupt blood flow in the brain o Forgetting current or past events, Misplacing items o Impaired abstraction, mental flexibility, processing speed, and working memory o Verbal memory is better preserved o Slower cognitive decline o Dementia occurs months within a stroke o Hallucinations or delusions o Trouble following instructions or learning new information o Onset: 65+ Lewy Body Dementia o Cause: abnormal deposits of protein called lewy bodies affect the brain's chemical messengers o Visual hallucinations o Spontaneous parkinsonisms- muscle rigidity, loss of coordination, reduced facial expression o Cognitive fluctuations o Visuospatial, attention, and executive function deficits are worse o Memory impairment not as severe o Earlier presentation of personality changes and psychosis o REM sleep disturbances, insomnia, increased daytime sleepiness o Onset: 50+ Frontal Lobe Dementia o Cause: Abnormal amounts of Tau and TDP-43 accumulate in in the neurons of the frontal and temporal lobes o Progressive behavioral or personality changes that impair social conduct o Impulsive behaviors, emotional extremes (flatness or excessive) o Language impairment- difficulty making or understanding speech o Possible preserved episodic memory o Shaky hands, problems with balance and walking o Onset: between 45 & 64 Donezepil (Aricept) o Cholinesterase inhibitor o GI side effects: nausea/vomiting, diarrhea, (resolve within 3 weeks of use) o Bradycardia found usually in those with underlying heart disease o CYP-450 metabolism o Indicated for mild to severe cognitive impairment o Slows the progression of memory loss o Diminishes apathy, depression, hallucinations, anxiety, euphoria, purposeless motor behaviors o Helps retain cognitive and adaptive faculties at a stable level for several months o May be beneficial for Lewy body dementia and vascular dementia o Warning: may cause catastrophic reaction with signs of grief and agitation- DC use. Galantamine o Cholinesterase inhibitor o GI side effects: dizziness, headache, nausea/vomiting, diarrhea, and anorexia (mild and transient) o CYP450 metabolism o Indicated for mild to moderate memory impairment o Rarely prescribed Memantine (Namenda) o NMDA receptor antagonist o May protect cells from excess glutamate by partially blocking NMDA receptors o Indicated for moderate to severe memory impairment o Fewer side effects than cholinergics, titrate over 4 weeks to target dose o Safe and well tolerated o Side effects: dizziness, headache, constipation, and confusion Do not use in severe renal impairment The risks of prescribing antipsychotics for patients with dementia · Black Box warning for all anti-psychotics · Increased risk of mortality of elderly patients with dementia-related psychosis · Primarily due to increased risk of cardiovascular events · Weigh risks vs benefits. · Know for education for families and patients Depression vs. Dementia · Depression o Onset can be dated with some precision o Rapid progression of sx after onset o Patients usually complain of some cognitive loss o Patients emphasize disability o Patients usually communicate strong sense of distress o Dysfunction at night uncommon Dementia vs. Depression Dementia o Onset is slow and insidious o Slow progression of sx throughout course o Patients usually complain little of cognitive loss (they don’t notice it, family does) o Patients conceal disability o Patients often appear unconcerned o Dysfunction at night (sun downing) common Insomnia Disorder o Symptoms must occur at least 3 nights/week for 3 months o Difficulty falling asleep, difficulty staying asleep, early morning awakenings o Exclusion of medical disorder, medications, substances, another sleep wake disorder, insufficient opportunity for sleep Hypersomnia o Symptoms must occur for at least 3 nights/week for 3 months o Multiple episodes of sleeping within the same day o Main sleep lasts >9hrs, but is nonrestorative o Difficulty to be fully aroused when woken o Excessive daytime sleepiness Klein/ Levin Syndrome o Most common in adolescent boys o Type of hypersomnolence o At least two episodes of excessive sleepiness and sleep duration, each persisting from two days to 5 weeks o Episodes occur multiple times a year, but at least once every 18 months o Patient has normal alertness, cognitive function, behavior, and mood in between episodes. o At least one of the following during an episode: cognitive dysfunction, altered