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10/4/2016 Challenges of Geriatric Patients Nurse Practitioners of - - PDF document

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10/4/2016 Challenges of Geriatric Patients Nurse Practitioners of Oregon 39 th Annual Education Conference DATE: October 14, 2016 PRESENTED BY: Laura M. Bryant, M.S.N., R.N. Director: Tuality Center for Geriatric Psychiatry AMYLOID PLAQUES

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Challenges of Geriatric Patients

Nurse Practitioners of Oregon 39th Annual Education Conference

DATE: October 14, 2016 PRESENTED BY: Laura M. Bryant, M.S.N., R.N. Director: Tuality Center for Geriatric Psychiatry

AMYLOID PLAQUES

Found in the spaces between the brain’s nerve cells. They consist largely of insoluble deposits of a toxic protein peptide: Beta-amyloid. Research has discovered that some people develop plaque with the aging process. The Alzheimer’s Dementia brain has many more

  • plaques. It is still

unknown if plaques cause Alzheimer’s Dementia or are a byproduct of the disease process.

NEUROFIBRILLARY TANGLES

Abnormal collections of twisted protein threads found inside nerve

  • cells. Major component of tangles is a

protein called Tau.

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In healing areas, tau is found in multiples areas of the body,

  • rganized in orderly parallel

strands and helps food molecules travel along tracks. Tau can misfold or collapse into twisted strands called tangles, “tracks” then fall apart and

  • disintegrate. (similar to prior

protein-viral type illness. Note: TBI, concussions, CTE (chronic traumatic encephalopathy) Found mostly in neurons, are proteins that stabilizes microtubules and are important in maintenance of cellular structure.

TAU: Rhym es with WOW Dementia: senility, hardening of the arteries, senile dementia dates back to ancient Greek philosophers. The old versus the new Dementia(a catch all) verses neuropsychiatric neurocognitive disorder 1906

  • Dr. Alois Alzheimer links symptoms of microscopic

brain changes to his famous Auguste D. Case. He discovered: memory loss, unfounded suspicions about her family; found dramatic shrinkage and abnormal deposits in nerve cells.

1910

Alzheimer's disease named

1931

The electron microscope was invented

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1968 Development of cognitive measurement scale: Researchers develop the first validated measurement scale for assessing cognitive and functional decline in older adults 1974 National Institute of Aging Founded The primary federal agency supporting Alzheimer’s research. 1984 Beta-amyloid Identified A novel cerebrovascular amyloid protein Chief component of Alzheimer’s brain plaques Prime suspect in triggering nerve cell damage 1986 Discovered “Tau protein” 1987 First determinate gene identified. 1993 First Alzheimer’s risk factor gene identified APOE-e4 – Raises risk for disease but is not determinate who will develop the disease 2004 Initiative to establish standards for brain imaging. 2011 United States establishes the framework for a national strategic plan to coordinate responses including research, care and support ** The difficulty in diagnosing is that most testing can only be conclusive during autopsy.

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  • Interference with ability to

function at work or usual activities

  • Functional decline
  • No delirium or psychiatric

disorder.

  • Cognitive impairment- history,

mental status, neuro-psych testing

  • Memory and Impaired

Reasoning

  • safety
  • Finances
  • poor decisions
  • inability to do complex or

sequential activities

  • Impaired visuospatial ability

(aren’t able to recognize faces, common objects, find things,

  • rient their clothes.
  • Impaired Language
  • Common words
  • Spelling
  • Changes in behavior (mood

agitation, apathy, sexualized behavior, profanity)

  • Aggression
  • Executive function impaired

reasoning judgment and problem solving (non-Amnesic)

  • Alzheimer's Dementia: 50-70 %
  • Vascular Dementia: 25%
  • Dementia with Lewy Bodies: 15%
  • Frontotemporal Lobe Dementia: 5-8%
  • Creutzfeldt-Jakob disease
  • Huntington’s Disease
  • 20% of young onset
  • Alcohol related Dementia
  • Wernicke-Korsakoff syndrome
  • Parkinson’s Disease Dementia
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It is Progressive… Degenerative… Irreversible

  • Three General Stages
  • Mild (Early Stage)
  • Moderate (Middle Stage)
  • Severe (Late Stage)

Longer course 1-10 (or 2-7, or 3-6?) The most prevalent brain cerebral atrophy (progressive loss of brain cells- entire brain or parts, reduced brain masses, shrinkage.) Causes of Alzheimer’s Dementia are unknown

  • There is a belief of genetic component 49%-79%

But it is not a disease itself. It relates to a number of common symptoms. Symptoms progress, overlap, ebb some but mostly progressive. SYMPTOMS INCLUDE:

  • Short term memory loss
  • Decline in language
  • Disorientation
  • Mood swings
  • Loss of motivation
  • Inability to complete even the

simple self care

  • Behavioral issues.
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MEDICATIONS: Mild to Moderate:

  • Rozadeyne
  • Excelon
  • Aricept
  • Namenda
  • cholinesterase

inhibitors- prevent breakdown of acetylcholine. Moderate to Severe:

  • Namenda

(regulating glutamate/ too much kills brain cells.)

  • may be used in

severe with Aricept. Off label medications for more severe behavioral symptoms. Anti-psychotics:

  • Zyprexa
  • Seroquel
  • Risperidal

Mood Stabilizers:

  • Depakote (Valproic Acid)

Remember start low, go slow. Check Labs for Therapeutic Levels Ex: Depakote- valproic acid levels. MEDICATIONS General term used to describe symptoms related to decline in thinking skills, reasoning, planning, judgment and memory caused by conditions that block or reduce blood flow to the brain. CAUSES

  • Infarct in brain tissues: large or

small

  • Long Time Chronic medical

conditions that stress brain tissues

  • Hypertension
  • Heart Disease
  • COPD
  • Diabetes
  • High Cholesterol
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  • Thorough medical history,

including family history of dementia

  • CT Scans
  • Looks at brain

structure

  • MRI Scans
  • Look at structure and

blood vessel abnormalities

  • Carotid Ultrasound
  • Looks at supply,

structure and plaques

  • Neurospych and Cognitive

testing CT Atrophy MRI Atrophy FDA has not approved of any drugs specifically to treat symptoms

  • f vascular dementia.

However, utilization of medication for underlying conditions can be helpful Prescriptions for some Alzheimer’s medications can also help boost the level of brain cell messages Research is ongoing: Researchers at Harvard Stem Cell Institute at Massachusetts General Hospital in Boston have showed that by manipulating proteins in the hippocampus may result in stronger, more precise memories. Of course more research is needed, but it does sound promising!

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An abnormal build-up of protein which form Lewy bodies –similar to Parkinson’s protein. They also have plaques/ tangles which affect men more. The 2nd most common type of progressive, degenerative brain disorder Patients suffer a progressive decline in mental ability includes symptoms of: Visual Hallucinations:

  • people
  • Shapes
  • Animals

Movement disorders:

  • Parkinson’s
  • slowed movements
  • rigid muscles
  • Tremor
  • shuffling gait

Poor Regulation of body functions:

  • Autonomic Nervous System
  • Blood Pressure
  • Pulse
  • Sweating
  • Gastro Intestinal Disturbances

Cognitive problems:

  • Alzheimer’s dementia
  • Confusion
  • Poor attention
  • Visual/ Spatial problems
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Sleep Difficulty:

  • REM sleep disturbances in which people

act out their dreams during sleep Fluctuating Attention:

  • Episodes of drowsiness
  • Long periods of staring off “into space”
  • Long naps during the day
  • Disorganized speech
  • Depression
  • Apathy
  • Severe Dementia
  • Aggression
  • Agitation
  • Increased risk of falls
  • Worsening Parkinson’s-like

symptoms

  • Death on average of 8 years

Medications:

  • Cholinesterase inhibitors
  • Rivistigmine/ Exelon – may help

alertness, cognition and reduce hallucinations

  • Side Effects:
  • GI Upset
  • Drooling/ Tearing
  • Frequent Urination
  • Parkinson’s Medications:
  • Sinemet - May reduce rigid

muscles, slow movements but increase confusion

  • Side Effects:
  • Hallucinations and

Delusions Antipsychotics (off label): DO NOT USE HALDOL.

  • Consider:
  • Sinemet and low dose

Seroquel

  • Zyprexa (Olanzapine)
  • Risperdal (Risperidone)
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An umbrella term for a diverse group of uncommon disorders that primarily affect the frontal and temporal lobes of the brain-the areas generally associated with personality, behavior and language and affect people at a younger age (between 40-65). Two Types:

  • Accumulation of Tau
  • Protein TDP-43 (microscopic

abnormal tau in Pick’s disease)

  • In many cases the patient does not realize that

they have a problem.

  • No Specific diagnostic tests, history, brain scans,

neuro-psych or cognitive testing can discover.

  • No known risk factors, however there are a

higher incidence in families so genetics may play a role. Behavior Changes: The most common signs and symptoms of frontotemporal lobe dementia involve extreme changes in behavior and personality.

  • Increasingly inappropriate actions
  • Loss of empathy and other interpersonal skills
  • Lack of judgement and inhibition
  • Apathy
  • Repetitive compulsive behaviors
  • Decline in personal hygiene
  • Changes in eating habits, predominately overeating
  • Speech and language problems
  • Impairment or loss of speech
  • Language difficulties

Antidepressants:

  • May reduce behavioral

problems

  • Trazodone (Oleptro)
  • Selective Serotonin reuptake

inhibitors (SSRIs) are effective in some but do have mixed results

  • Sertraline (Zoloft)
  • Paroxetine (Paxil)
  • Fluvoamine (Lovox)

MEDICATIONS Antipsychotics:

  • Combat behavioral problems

however side effects include an increased risk of mortality in

  • lder adults.
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel
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  • Supportive, quiet, low

stimulus environment with good natural light.

  • Encourage rest, fluid intake.
  • Realize that dementia

patients like pudding, jello, ice cream, milk shakes, spaghetti, chopped chicken, mashed potatoes, comfort foods.

  • Monitor for constipation

and UTI- both with make dementia worse or way worse!

  • Monitor for any type of

infection- pneumonia. Try to stay to routine. Get the patient outside! - WALK even SIT or STAND

  • Swallow Studies
  • Pet Therapy
  • Music Therapy
  • Physical Therapy
  • Movement Therapy
  • Aroma Therapy
  • Monitor response to drugs very carefully for

changes, sedation adverse responses, sometimes for several days after initiation of therapy if titrating.

  • Monitor for high fall risk due to sedation,

confusion, walking for hours, misperceiving the environment, picking at items on the floor.

  • Monitor visual and hearing changes and

deficits.

  • Talk simply, concrete, gently.

Understand that Dementia will be worsened by:

  • Infectious disease
  • Fever
  • Fractures
  • Surgeries
  • Changes in the environment
  • Caregivers

MAKE SURE caregivers have support!

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  • Provide support for

families

  • Educate caregivers
  • Provide safer places to

live:

  • assisted living
  • memory care
  • enhanced memory

care PLEASE ENCOURAGE YOUR PATIENTS!!!

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Alzheimer’s Association. Alz.org research center, 2016, alz.org/ research/ science/ major_milestones_in_alzheimers.asp. Accessed 23, September, 2016. Frontier in Bioscience. Brain MRI in Parkinson’s disease. Elite, 6, 360-369, June 1, 2014. https:/ / www.bioscience.org/ elite/ 8e/ 2016. Accessed 23, September, 2016.

References

Mayo Clinic. CT scan of brain tissue dam aged by stroke. http:/ / www.mayoclinic.org/ diseases- conditions/ stroke/ multimedia/ img-20116031. Accessed 23, September, 2016. Hebert LE, Weuve J, Scherr PA, Evans DL. Alzheimer disease in the United States (2010–2050) estimated using the 2010 census. Neurology. 2013;80:1778-83. McAvoy K.M., et al. Modulating neuronal competition dynamics in the dentate gyrus to rejuvenate aging memory

  • circuits. Neuron. Published online Sept. 21, 2016.

National Institute on Aging. Identifying m echanism s that m ay keep m em ories sharp in the aging

  • brain. September 23, 2016.

https:/ / www.nia.nih.gov/ newsroom/ announcements/ 2016/ 09/ identifying-mechanisms-may-keep- memories-sharp-aging-brain. Accessed 23, September, 2016. National Institute on Aging. Alzheim er’s Disease: Unraveling the Mystery. January 22, 2015. https:/ / www.nia.nih.gov/ alzheimers/ publication/ part-2-what-happens-brain-ad/ hallmarks-ad. Accessed 23, September, 2016.