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

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Presentation on theme: "Cognitive Disorders ECT Phyllis M. Connolly, PhD, RN, CS NURS 127A."— Presentation transcript:

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

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

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

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 Tips for Working with Persons with Dementia 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 Promote SafetyCommunication

20 Tips for Dementia Care Cont. 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 Decrease Confusion

21 Tips for Dementia Care Cont. 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 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% O 2 Electrical impulse 150 volts, 0.5 - 2 sec. Monitor, heart rate, rhythm,BP, EEG

26 Nursing Care After ECT Ventilate with 100% O 2 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 Contraindications for ECT 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

28 Disadvantages ECT Temporary relief Memory impairment, before and after ECT Physiological effects –hypertension –arrhythmias –alterations in cardiac output –hemodynamic changes –increases in myocardial o 2 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 – 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


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