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Cognitive Disorders ECT Phyllis M. Connolly, PhD, RN, CS NURS 127A 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? 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 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 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 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 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 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 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 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 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 Impaired Cognitive Functioning • Key Elements of Care – – – – – Communication Orientation Structure Stimulation Safety 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 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 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 Comparison Dementia, Delirium & Depression Dementia Delirium Depression Cause may be unknown Can become chronic Insidious Cause may be identified Time limited Cause may be identified Time limited Acute onset Insidious Not often treatable Always treatable or reversible Consciousness, Clouded normal Usually treatable Normal Psychotherapeutic Management • Nurse-Patient Relationship • Psychopharmacology – – – – Antipsychotics Antidepressants Antianxiety Treatment of cognitive impairment • cholinergic enhancers • metabolic enhancers/vasodilators • Nootropic agents – Milieu management • Safety 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 Tips for Working with Persons with Dementia Promote Safety • 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 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 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 Tips for Dementia Care Cont. Physical & Emotional Wellbeing • 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 Family Education • 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 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 Disorders, Depressive Symptoms, & Conditions Responding to ECT DISORDERS DEPRESSIVE SYMPTOMS Severe depression Anhedonia 85 – 90% CONDITIONS Tardive dystonia Treatmentrefractory depression Catatonia Anorexia Tardive dyskinesia Delusions Akathisia Mania Insomnia Some types of schizophrenia Muteness Parkinsonian symptoms Neuroleptic malignant syndrome Psychomotor retardation Suicidal ideation 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 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 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 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 Disadvantages ECT • Temporary relief • Memory impairment, before and after ECT • Physiological effects – hypertension – arrhythmias – alterations in cardiac output – hemodynamic changes – increases in myocardial o2 consumptionischemia – seizures Other Somatic Therapies • Psychosurgery • Insulin-Coma • Metrazol-induced convulsions Psychosurgery • Types – Cingulotomy – Subcaudate tractotomy – Capsulotomy • Outcomes, psychosurgeries – Suicide rate of 1300 persons dropped 15% to 1% post op • Contraindications – – – – <20 yrs or >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 Phototherapy: Seasonal Affective Disorder • Light box • Phototherapy visor • Head-mounted light unit • Dawn stimulator