Ch. 29, 30, 31 - Older Adult Mental Health
Terms
undefined, object
copy deck
-
Case Study:
68 year old male admitted to ER. Family report that he has been AGITATED, AGGRESSIVE, & has been WANDERING away from home. V/S normal. Blood work - Hgb is BELOW normal value. All other reports are okay. -
- Has history of past alcohol abuse (long term) but has not been drinking for past 6 years. Functions independently at home. Family report that over the past 6 months he has become forgetful and wanders away from the house
- he is admitted to the medical ward & blood transfusions are initiated. During the transfusions he spikes a temperature and becomes increasingly DISORIENTED, AGITATED, AGGRESSIVE & strikes the nurse. Speech is incoherent.
- He is sedated & transferred to the psychiatric unit until a bed is available at the Waterford. Diagnosis of DEMENTIA. - Statistics related to Older Population:
-
- 1921: 5% of Canadians were 65 & older
- 2031: nearly 25% (1/4) of the population will be in this age group (of this population, an increasing number will experience some form of altered mental status) - Risk Factors for Mental Health Problems in the Older Adult:
-
1. CHRONIC ILLNESSES
2. POLYPHARMACY
3. Bereavement & LOSS
4. POVERTY
5. Suicide & the Lack of SOCIAL SUPPORT - PRIMARY Mental Health disorders of the Older Adult:
-
1. Delirium
2. Depression
3. Dementia
4. Others (suicide, substance abuse, anxiety, paraphrenia) - PARAPHRENIA:
-
- Disorder of late life characterized by PERSECUTORY DELUSIONS & ABSENCE of COGNITIVE IMPAIRMENT
- Suspicious but COGNITIVE function is STILL INTACT - OLDER persons with SCHIZOPHRENIA:
-
- usually LONGSTANDING problems (ex. related to housing, lifestyle, poverty)
- years of PSYCHOTIC medications
- Exacerbations may occur with STRESSES of age
- may become more WITHDRAWN or PARANOID
- Most often: HALLUCINATIONS become less and DELUSIONS may DISAPPEAR
- Not unusual to IMPROVE with age - LATE onset SCHIZOPHRENIA:
-
- more common in WOMEN
- PARANOID type is more common
- tend to have LESS SEVERE:
1. NEGATIVE SYMPTOMS
2. LESS COGNITIVE IMPAIRMENT
3. BETTER PROGNOSIS
- a small portion will have onset AFTER 65 (very late-onset schizophrenia-like psychosis)
- Depression and the Older Adult:
-
- when an elderly person has the feeling that life is not worth living, you should always check for depression (***having lost interest in life is NOT a normal consequence of aging; generally people are HAPPIER in older life)
- *DEPRESSION is a risk factor for STROKE
- elderly are more vulnerable to depression because of mental and physical stressors and problems and losses later in life
- Medications
- also a result of Left-sided CVA (cerebrovascular accident; stroke)
- 4 times HIGHER in INSTITUTIONS (routine becomes regulated)
- lifelong untreated depression leads to dementia
- long term depression can lead to diabetes due to STRESS
- Qualitatively DIFFERENT in older adults
- RISK INCREASES with age
- in late life, it may be a RELAPSE of earlier depression or triggered by an event (ex. admission to nursing home, meds, illness) - DEPRESSION (MULTIFACETED SYNDROME)
-
1. Affective
2. Cognitive
3. Somatic
4. Physiologic manifestations - 3 SUBTYPES of LATE LIFE DEPRESSION:
-
1. EARLY onset
2. LATE onset
3. LATE onset with VASCULAR risk factors (ex. stroke) - DEPRESSION SYMPTOMS:
-
- *Depressed mood
- *Loss of interest in usual activities
- *Weight gain/loss (5%) of normal weight
- **Disturbed sleep patterns
- *Fatigue & loss of energy
- *Agitation or generalized slowing of body activity
- **Feelings of worthlessness
- Impaired thinking or concentration
- Recurrent thoughts of death or suicide
- Social isolation/withdrawal
*most experience DYSPHORIA (generalized dissatisfaction with life) & depressive symptoms - DEPRESSION DIAGNOSTIC CHALLENGES in the older adult:
-
- absence of depressed mood
- presence of cognitive impairment, dementia or delirium - DELUSIONS associated with DEPRESSION:
-
- the themes of the delusion may be clues to the presence of an affective disorder - especially if the focus is on a RECENT LOSS
(Ex. Mrs. N believes she is responsible for her husband's death, therefore she believes that she does not deserve help for her own illness) - GERIATRIC DEPRESSION RATING SCALE:
-
- ***DOES not DIAGNOSE depression
- screening tool for depression. It is a 30 item form with a rating SCORE of 10-19 points indicating MILD CASE and GREATER THAN 20 points indicating a SEVERE CASE
- a short form of 15 questions is also used - TREATMENT for DEPRESSION in older adults:
-
1. When starting an elderly person on ANTIDEPRESSANTS: START LOW & GO SLOW
2. Freedom to choose and be responsible for choices - protected community living older people (INDEPENDENCE)
3. Providing a PURPOSE, sense of order, a reason for existence and an OPTIMISTIC outlook - protected institutionalized
4. TRICYCLICS and MAOI's are NOT used as often in the elderly
5. SSRI's (USED MORE OFTEN) - because of DECREASED side effect profile
5. Counseling
6. ECT (electroconvulsive therapy)
7. Support groups
8. Day Hospital Treatment Programs
9. Social/Community Groups
10. Combination of medications and above items - THERAPIES for DEPRESSION in older adults:
-
1. Volunteer work
2. Hobbies
3. Pet therapy
4. Music therapy
5. Humor therapy
6. Reminiscence
7. Depression education
8. Bereavement therapy - SUICIDE in older adults
-
- **MALES in the 80+ age group: HIGHEST suicide rate for any age group!!
- loss is a major theme in suicide
- most common method for men: guns and hanging - TYPES OF DEMENTIA:
-
1. ALZHEIMER'S DISEASE
2. VASCULAR DEMENTIA
3. FRONTOTEMPORAL DEMENTIA
4. DEMENTIA WITH LEWY BODIES (MAD COW) - PREVALENCE RATES for dementia:
-
- PREVALENCE of DEMENTIA increases dramatically with AGE
- 70 - 3%
- 79 - 11%
- 85 - 30%
- 95 - 50% - What is DEMENTIA?
-
- COGNITIVE issues
- progressive, PREDICTABLE deterioration
- decline in JUDGMENT, AFFECT, MEMORY, COGNITION, ORIENTATION
- Decline in Language and Perception
- Functional problem in language and perception
**CONFABULATION: making things up (covering up memory loss) - COGNITIVE DEFICITS related to DEMENTIA
-
- MEMORY impairment (PLUS 1 of the following):
1. APHASIA (loss of ability to understand or express speech)
2. APRAXIA (inability to perform particular purposeful movements)
3. AGNOSIA (inability to interpret sensations and recognize things)
4. DECLINE in EXECUTIVE functioning -
PSEUDODEMENTIA: (False dementia - they exhibit symptoms of dementia but the cause is depression)
VS.
DEMENTIA -
- Past episodes/family history of depression
- ABRUPT onset
- complaints of MEMORY LOSS
- answers "I don't know" (instead of confabulating)
- depressed mood and physical symptoms
- marked DEPENDENCY
VS.
- Family history of DEMENTIA
- GRADUAL onset
- CONCEALMENT denial (confabulation)
- ATTEMPTS to answer questions
- MOOD fluctuates
- STUGGLES to maintain - DEMENTIA leads to:
-
- BEHAVIOURAL problems
- DELUSIONS & HALLUCINATIONS
- PERSONALITY changes
*IRREVERSIBLE - PROFOUND DEPRESSION:
-
- lack of affect
- confusion
- apathy withdrawal
- retarded speech & movement
- poverty of thought
- agitation
- inattention to self
- insomnia
- delusions
- body preoccupation - DIAGNOSIS of DEMENTIA:
-
SIGNIFICANT impairment of 2 OR MORE BRAIN FUNCTIONS:
1. LANGUAGE
2. MEMORY
3. VISUAL-SPACIAL
4. PERCEPTION
5. EMOTIONAL BEHAVIOUR OR PERSONALITY
6. COGNITIVE SKILLS
***FAMILY input is VITAL (they can tell you the norm. If you don't know the norm, you misjudge) - DELUSIONS OF DEMENTIA:
-
- NOT fixed
- NOT well organized
- readily CHANGED/FORGOTTEN
- themes: FEAR, THEFT, CONCERN regarding DEPRIVATION - DELUSIONS associated with (PSYCHOSIS vs. DEMENTIA):
-
- PSYCHOSIS: COMPLEX delusions (more complicated and rigid)
- DEMENTIA: SIMPLE PERSECUTORY delusions (elementary, loosely structured, usually transient) - DELUSIONS associated with DEMENTIA:
-
- commonly involve MISIDENTIFCATION or a FALSE BELIEF about PEOPLE or the ENVIRONMENT (accuse caregiver of wanting to harm them)
- Belief they're NOT in their OWN HOME leads to WANDERING and AGITATION wanting to find home
- Belief that deceased parents or other close relatives are still alive - precipitates agitation & searching
*Delusions: misidentification or a false belief - ASSESSMENT for DEMENTIA:
-
- the nurse will be EASLIY given information by the patient - this CONTRASTS the secretiveness and withholding of information that is TYPICAL of NON-dementia persons
*people with dementia confabulate (make up things) and people with non-dementia withhold or say, "I don't know" - INTERVENTIONS for DEMENTIA:
-
- Life maintenance - depends on the stage and amount of cognitive disturbance
- Reality orientation is appropriate for the patient who CAN PROCESS the INFORMATION
- the environment needs to be appropriate for SAFETY and ORIENTATION
- resistance or aggression may be a protective factor (assess for fear of pain)
- http://www.youtube.com/watch?feature=playerdetailpage&v=AFKACRqNJFE
Tips from video:
Patient Question: "Have I ever told you I'm from West Virginia?"
- Don't say, "Yes" or "No"
- say, "Tell me about it"
- when the same question is asked over and over, it is a good thing (reminiscing gets brain cells firing)
*reorient patients who are in EARLY stages
*try and keep them functioning as much as possible - What is DELIRIUM?
-
- ***ACUTE, REVERSIBLE disorder
- clouding of awareness
- fluctuating level of awareness
- overwhelming anxiety
- Florid (elaborate) DELUSIONS
- Frightening ILLUSIONS
- Tacile, visual, olfactory HALLUCINATIONS (***Note: dementia hallucinations differ from psychotic hallucinations)
- usually caused by a MEDICAL condition (SECONDARY)
- DELIRIUM is a medical emergency - TYPES of DELIRIUM:
-
1. HYPERACTIVE DELIRIUM: MOST COMMON
2. HYPOACTIVE DELIRIUM: (quieter)
- inactivity
- withdrawn
- sluggish behaviour
- most commonly UNDER RECOGNIZED - CAUSES of DELIRIUM:
-
*in order of frequency:
1. Medications
2. Infections
3. Fluid/electrolyte imbalance
***see handout (p.3) - CAM Identifying Risk Factors:
-
- ACUTE change
- Inattention
- Rambling, disorganized thinking
- altered level of consciousness
*See handout - Nursing Considerations for DELIRIUM:
-
- consider delirium an EMERGENCY
- required IMMEDIATE intervention
- vitals & neurological status
- assess for DRUG TOXICITY, INFECTION & FLUID/ELECTROLYTE IMBALANCE
- targeted history from patient and family (vital)
- Blood and Urine samples
- **remember that they are AFRAID (keep # of staff minimal around them)
- say their NAME FREQUENTLY and AVOID sudden movements
- treat MEDICALLY
- Use RO (reorientation) in lucid (understandable) moments
- well lit environment
- proper MEDICATION
- SIMPLE DIRECT statements
- weave reality statements into conversation (ex. 'here at the hospital' or 'now that it is June')
http://www.youtube.com/watch?v=lJH1AoVuVS0&feature=playerdetailpage
- avoid standing over patient and speaking loudly - COMPARISON of DELIRIUM vs. DEPRESSION
-
DELIRIUM:
- Onset: acute
- Duration: Short
- Course: Fluctuating
- Sleep cycle: REVERSED
- Sensorium: Clouded
- Speech: Incoherent
- Perception: Distorted
- Prognosis: Often reversible
DEPRESSION:
- Onset: gradual
- Duration: long
- Course: steady
- Sleep cycle: unchanged
- Sensorium: clear
- Speech: coherent
- Perception: clear
- Prognosis: often chronic - NURSING CONSIDERATION KALEIDOSCOPE OF CARE STRATEGIES:
-
- obtain through history from client, family and significant others
- cognitive assessment
- ***use knowledge of client's home, work, etc. as part of the care
- assess for all 3 conditions (delirium, dementia, depression) by:
1. Knowing the person
2. Relating effectively
3. Recognizing retained abilities
4. Manipulating the environment
- For depression, the main goal is to alleviate the depressed state
- For delirium, the main goal is to alleviate underlying medical condition
- For dementia, the main goal is to "maintain the status quo"