Cognitive Disorders ECT

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Cognitive Disorders ECT

• Phyllis M. Connolly, PhD, RN, CS
• NURS 127A

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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?

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Cognitive Impairments

• 2.4 million Americans suffer from dementing
  illnesses
• 7.3 million by 2040
• Alzheimers Disease
• Dementias
• Vascular--interruption of blood flow to brain
• Parkinsons--involves extrapyramidal
• Diffuse Lewy Body Disease
• Huntingtons Disease
• Creutzfeldt-Jakob Disease
• Alcoholic Dementia
• TIA

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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

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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

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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 Alzheimers

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Four As of Alzheimers 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

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Alzheimers 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

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Alzheimers 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

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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

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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

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Impaired Cognitive Functioning

• Key Elements of Care
• Communication
• Orientation
• Structure
• Stimulation
• Safety

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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

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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

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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

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Comparison Dementia, Delirium Depression
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Psychotherapeutic Management

• Nurse-Patient Relationship
• Psychopharmacology
• Antipsychotics
• Antidepressants
• Antianxiety
• Treatment of cognitive impairment
• cholinergic enhancers
• metabolic enhancers/vasodilators
• Nootropic agents
• Milieu management
• Safety

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Validation Therapy

• Enter clients world rather than force to relate
  to an external world which is no longer
  comprehensible
• Increase the clients sense of being understood
  by others
• Reduces agitation and catastrophic reaction
• ?quality of life

Schober, Glod, Jones, 1998, p .252
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Tips for Working with Persons with Dementia

Promote Safety
Communication

• 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

• 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

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Tips for Dementia Care Cont.
Decrease Confusion

• 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

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Tips for Dementia Care Cont.
Physical Emotional Wellbeing
Family Education

• 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

Schober, Glod, Jones, 1998, p. 251
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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

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Disorders, Depressive Symptoms, Conditions
Responding to ECT
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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

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Procedures During ECT

• IV inserted
• Electrodes placed on head
• Bite-block inserted
• Brevital IV
• Anective IV, neuromuscular blocking agent
• Ventilate 100 O2
• Electrical impulse 150 volts, 0.5 - 2 sec.
• Monitor, heart rate, rhythm,BP, EEG

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Nursing Care After ECT

• Ventilate with 100 O2 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

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Contraindications for ECT

• 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

• Very High Risk
• Recent myocardial infarction
• Recent CVA
• Intracranial mass lesion
• No absolutes

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Disadvantages ECT

• Temporary relief
• Memory impairment, before and after ECT
• Physiological effects
• hypertension
• arrhythmias
• alterations in cardiac output
• hemodynamic changes
• increases in myocardial o2 consumption-ischemia
• seizures

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Other Somatic Therapies

• Psychosurgery
• Insulin-Coma
• Metrazol-induced convulsions

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Psychosurgery

• Types
• Cingulotomy
• Subcaudate tractotomy
• Capsulotomy
• Outcomes, psychosurgeries
• Suicide rate of 1300 persons dropped 15 to 1
  post op
• Contraindications
• lt20 yrs or gt65 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

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Phototherapy Seasonal Affective Disorder

• Light box
• Phototherapy visor
• Head-mounted light unit
• Dawn stimulator