Mood

1
Mood Cognitive Disorders in the Older
Adult-The Most Common Mental Health Problem in
Late Life
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Theories of Late Life Depression

• Psychosocial Theory
• Multiple lossesloss of self-esteem
• Meaning and purpose of lifelearned helplessness
  one expects bad things to happen
• Protective Measures- provide freedom to make
  choicespurpose/reason for existencestrengthen
  self-efficacy

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Theories

• Cognitive Triad Theory (Beck)
• People appraise themselves by viewing ones
  self-image, environment, future.
• Depressed person judges self as lacking features
  necessary for happiness.

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Becks theory

• Three components
• Cognitive distortions (person unable to
  accurately appraise self)
• Schemas (assumptions that influence
  thoughts,feelings,behaviors)lead to faulty
  conclusions
• Logical Errors (personalization,
  minimization,over generalizations)

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Biologic Theories

• Relationship between Aging,Depression, Bio
  Chemical changes in the brain, nervous system and
  neuro-endocrine system.
• Neurotransmitters Seratonin, Dopamine,
  Acetylcholine, Norepinephrine, cortisol levels,
  altered growth hormone secretion,altd thyroid

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Assessment of Needs
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Functional Consequences of depression older
adult

• Impact on physical health-
• lt functional capacity/ worse for those with
  cognitive impairment
• Mortality rates increased
• Physiologic changesbowels/sleep/lytes
• Psychomotor agitation/slowing
• Highest suicidal risk 25 of all suicides

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Younger Vs. Older adult

• More likely to report sx of depression sadness/
  expresses verbal/passive means of Suicide
• Hopelessness
• Helplessness
• Negative towards self
• Insomnia/eating d/o

• Reports cognitive
• physical changes
• Less talk about SI --
• More successful
• Apathy/emptiness
• Decd interest,wt loss
• Hypersomnia/early morning awakening

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Dementia vs. Depression

• Onset gradual
• Unaware of sxs
• Emotions labile
• Response evasive
• Appearance inappropriate
• Physical vague fatigue

• Triggered event
• Aware of memory changes
• Feelings of sadness
• I dont know response
• Not concerned re appearance

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Dementia vs. Depression

• Neurological Aphasia,agnosia, apraxia,persever-at
  ion
• Reality denial

• Anorexia/wt. Loss
• Insomnia/ reduced energy
• Neuro dysphasia
• w/o physiologic basis
• Increased sense of gloom

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Suicide assessment

• Up to 90 of older adults who commit suicide have
  an informant!!!
• gt15 of elders with chronic conditions are
  depressed
• Post Stroke depression common
• Prevalence in LTC 25 -gt stressors of chronic
  illness,disability, dementia,chronic pain,loss of
  spouse,relocation to institution

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Levels of Assessment

• Level I be aware for vocal clues to suicide
  intent ask Do you ever think life is not worth
  living or want to escape from your problem?
• Level II ask Do you think about harming
  yourself? or taking your own life?

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Suicide assessment

• Level III ask Do you have a plan?
• Ask what would you do?
• Level IV Ask Have you ever started to act on
  the plan? Under what circumstances would you act
  on this plan?

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Dementia vs. Delirium

• Onset- slow inscidious
• JOMAC s/sx.
• Progressive d/o
• Decline of functioning
• Psych Behavioral disturbances may occur
  Delusions/hallucinations/agitation/beligerence

• Onset rapid
• Cognition fluctuates
• Decreased attention
• Distractable
• Sensory disturbance/illusions
• Misinterpretation of stimuli
• 10-15 in hosp can suffer from delirium.

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Etiology Dementia v.s. Delirium

• Abnormal APOE gene identified in genetic AD
• Plaques tangles
• Cortical atrophy

• Identifiable condition
• Ie. Physiologic
• Metaboloic
• Cerebral disturbance
• Drug intoxication
• Poly-pharmacy

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Review questions the older adult with cognitive
mood disorders
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Scenario Older adult

• J.M. is an 82 y/o female admitted to the
  med-center for pneumonia. J.M. was found on the
  floor of her apt. where she had lay for 15 hours
  unable to get herself up. She could not recall
  how she fell. She is dehydrated, has difficulty
  following questions. When her daughter visits she
  tells her that a man is standing outside of her
  window with an umbrella. Her daughter reports
  this as unlike her mother who is usually clear
  and oriented.
• 1. What would you tell the daughter?
• 2. Is this Delirium or the onset of Dementia?
• 3. Prioritize Two nursing Dx. /outcomes/interventi
  ons

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• The nurse is talking to a woman who is worried
  that her mother has Alzheimers disease. She
  correctly tells the daughter that EARLY signs of
  dementia include
• Memory loss that is more than forgetfulness.
• Symptoms vary with different persons
• Disorientation to person, place and time
• Inability to perform self-care tasks without
  assistance.

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• The nurse has been teaching caregivers about
  donepezil(Aricept). The nurse evaluates the
  teaching to be effective by the following
  statement
• Ill be eager to see if this medication makes
  any improvement in concentration.
• This medication will slow the progress of
  Alzheimers disease temporarily.
• Lets hope this medication will stop Alzheimers
  disease from progressing any further.
• It is important to take this medication on an
  empty stomach.

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• A client with late moderate stage of dementia has
  been admitted to a long term care facility. Which
  of the following nursing interventions will help
  the client to maintain optimal cognitive
  function?
• Discuss pictures of children and grandchildren
  with the client.
• Do word games or crossword puzzles with the
  client.
• Provide the client with a written list of
  activities.
• Watch and discuss the evening news with the
  client.

21

• A client with delirium is attempting to remove
  the intravenous tubing from his arm, saying to
  the nurse Get this snake off me - Go away! The
  nurse recognizes that the client is experiencing
  which of the following
• Delusions
• Hallucinations
• Illusions
• Disorientation

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• Which of the following interventions is most
  appropriate for helping a client with early stage
  dementia complete ADLs ?
• Allow enough time for the client to complete
  ADLs as independently as possible.
• Tell the client to finish ADLs before breakfast
  or the nursing assistant will do them.
• Plan to provide step by step prompting to
  complete ADLS.
• Provide the client with a written list of all the
  steps to complete the ADLs.

23

• In admitting a client with Alzheimers disease to
  the unit. Which placement variable would have the
  highest priority?
• Place the client with a roommate.
• Place the client without a roommate.
• Place the client close to the nurses station.
• Place the client at a distance from the nurses
  station.

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• A client hospitalized with Alzheimers disease is
  found wandering in the streets. What measure(s)
  should be taken in the unit to prevent the client
  from wandering off?
• Place the client in daytime restraints.
• Place the client in nighttime restraints.
• Provide a security guard at the door.
• Use electronic surveillance devices.

25

• The nurse is conducting a home health assessment
  visit with an 84 year-old client who is living
  alone. Which aspect of lifestyle noted by the
  nurse would be of greatest concern?
• The family visits twice a month, and rarely
  calls.
• The family maintains only phone contact daily.
• The client uses a cordless telephone rather than
  a standard phone.
• The client prefers not to attend a senior center
  for meals and recreation.

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• Which of the following would the nurse
  incorporate in the care plan of a client with
  dementia to aid in memory retention?
• Daily activity schedule
• Large motor activities
• Simple word games
• Discussion groups

27

• The nurse is assessing an elderly client who
  presents with symptoms of decreased
  concentration, sadness, and somatic complaints
  using the Mini-Mental State Examination. This
  assessment is used for the purpose of
  differentiating depression from which of the
  following?
• Anxiety
• Dementia
• Paranoia
• Somatization

28

• An elderly client is hospitalized with pneumonia
  and treated with multiple antibiotics. After 2
  days, the client becomes irritable and restless,
  and says to the nurse , My pet parakeet flew
  across the room. A family member says the
  client has been healthy and living independently
  but does not own a pet. The most likely analysis
  of this scenario is
• The client is delusional and likely experiencing
  depression.
• The client is experiencing illusions secondary to
  delirium.
• Dementia has emerged as the result of the stress
  of the physical illness.
• The antibiotic doses have been inadequate to
  treat the infection.

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• A nurse is planning the care for a 79 year old
  client admitted with a diagnosis of late stage of
  
• Alzheimers disease. Which nursing
  diagnoses would be priorities to include?
• (select more than one)
• Risk for infection
• Acute confusion
• Risk for aspiration
• Impaired verbal communication
• Hopelessness

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• To most accurately assess an older adult for
  depression the nurse would ask the following
  question
• How do you compare your activities and health
  now to six months ago?
• Would you say you are currently having a major
  depressive episode?
• What is your family history related to
  depressive illnesses?
• Are you having crying spells every day?