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NUR 2488 Mental Health Nursing

Exam 2 Study Guide

Module 4 Neurological Disorders

Neurological Disorders includes conditions in which a clinical deficit in cognition or

memory exists, causing a change from a previous level of functioning.

Delirium

Delirium is a disturbance in attention and awareness and change in cognition that

develops rapidly over a short period. It most commonly occurs in individuals with

medical, surgical, or neurological conditions. Differentiating delirium from dementia can

be a complicated process, but failure to recognize delirium and the cause can delay

appropriate treatments causing severe consequences. It is also the most frequent

complication of hospitalization in older adults. It is associated with increased morbidity

and can have lasting long-term results, such as permanent cognitive decline.

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Examples of Causes

• Systematic infections

• Febrile illness

• Head trauma

• Seizures

• Migraine headaches

• Stroke

• Electrolyte imbalance

• Post-operative status

• Substance withdrawal

• Certain medications

• Substance intoxication

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Symptoms

• Disorganized thinking

• Speech that is rambling, irrelevant, pressured, incoherent

• Very distractible

• Lack of focused attention

• Disorientation

• Impairment of recent memory

• Misperceptions of the environment

• illusions

• hallucinations

• State of awareness my range from hypervigilance to stupor.

• Sleep may fluctuate between hypersomnolence and insomnia.

• Psychomotor activity may fluctuate between agitated, purposeless movements to a

state resembling catatonic stupor.

Emotional instability may be manifested by anxiety, fear, irritability, anger, euphoria, or

apathy. These emotions may be evidenced by crying, calling for help, muttering, and

moaning.

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Autonomic Symptoms

• Tachycardia

• Sweating

• Flushed face

• Dilated pupils

• Elevated blood pressure

The onset of the symptoms is usually quite abrupt, and duration is typically brief (1 week

- rarely one month)

Treatment

• The first step is to determine and correct the underlying cause

Pharmacological Treatment

• Antipsychotic (low-dose) haloperidol (Haldol)

• Benzodiazepine-commonly used if etiology is substance withdrawal. (lorazepam

(Ativan) or diazepam (Valium)

• B1 IV for thiamine deficiency

• Supplemental oxygen

Environmental Interventions (safety)

• Decrease stimulation

• Have family stay with the client

• Verbally orient to time, place and situations several times daily

• Place in a room close to the nursing station

• Place clock and calendar in the room

• Explanation of events

• Frequent reassurance

• Maintain a calm, structured environment

• Keep answers simple

• Consistent assignment of caregivers

• Involve family members in care

Dementia

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Dementia is a mental disorder involving a functional decline in multiple cognitive areas,

including memory, along with behavioral and psychological symptoms. Dementias are

classified according to the cause or areas of neurological damage.

Stages of Alzheimer’s Disease

• Stage 1 - No apparent symptoms

• Stage 2 - Forgetfulness

• Losses in short term memory are frequent. The individual begins to lose things or

forget names of people.

• Stage 3 - Mild cognitive decline

• In this stage, there is interference with performance, and this becomes noticeable

to others. There is difficulty recalling names or words. A downturn is noticeable to

family and close associates.

• Stage 4 - Mild to Moderate cognitive decline

• The individual may forget significant events in history, experience a declining

ability to perform tasks. He/she may deny a problem exists by covering memory

loss with confabulation (creating imaginary events to fill memory gaps).

• Stage 5 - Moderate cognitive decline

• The individual loses the ability to perform some activities of daily living

independently. He/she may forget addresses, phone numbers, and names of close

relatives and friends. Disorientation to time and place becomes more apparent.

• Stage 6 - Moderate to severe cognitive decline

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• Disorientation to surroundings is common and may not know the day, season, or

year. The person is also unable to manage AOLs without assistance. Urinary and

fecal incontinence are common.

• Psychomotor symptoms include wandering, agitation, and aggression. Symptoms

seem to worsen in late afternoon and evening (a phenomenon termed

sundowning).

• Stage 7 - Severe cognitive decline

• In the end stages, the individual is unable to recognize family members. He/she

most commonly is bedfast and aphasic. Decubiti and contractions may occur.

Other Neurocognitive Disorders

• NCD due to traumatic brain injury

• Vascular NCD

• Frontotemporal NCD

• NCD due to Lewy Body dementia

• NCD due to Parkinson’s disease

• NCD due to HIV infection

• Substance/medication-induced NCD

• NCD due to Huntington’s disease

• NCD due to Prion disease

How the Brain Changes

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An overabundance of structures called plaques and tangles appear in the brain of

individuals with Alzheimer’s disease. Amyloid Plaques are made of amyloid protein. This

clumps together and form between nerve cells is causing neuronal

destruction. Tangles form from a cellular protein called tau protein. Strands of protein

become tangled together, interfering with neuron transport. There is also brain atrophy.

Pharmacological Treatment

• donepezil (Aricept) cholinesterase inhibitor-all stages

• rivastigmine (Exelon) cholinesterase inhibitor-all stages

• galantamine (Razadyne) cholinesterase inhibitor-mild to moderate

• memantine (Namenda) blocks NMDA-moderate to severe

• donepezil and nemantine (Namzaric)- (combination)

How these drugs function:

Cholinesterase inhibitors keep the acetylcholinesterase enzyme from breaking down the

neurotransmitter acetylcholine. In Alzheimer’s disease, the brain is producing less of this

neurotransmitter, and this allows for more acetylcholine production.

In the brain of a client with Alzheimer’s disease (AD), there is also excessive glutamate,

which leads to chronic overexposure to calcium in the brain. This process is damaging to

the neurons. Memantine blocks N-methyl-D aspartate (NMDA) receptors, thus reducing

calcium.

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