Cognitive Disorders ECT

Phyllis M. Connolly, PhD, RN, CSNURS 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 & DepressionDementia Delirium Depression

Cause may beunknown

Cause may beidentified

Cause may beidentified

Can becomechronic

Time limited Time limited

Insidious Acute onset Insidious

Not often treatableor reversible

Always treatable Usually treatable

Consciousness,normal

Clouded 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 lifeSchober, Glod, Jones, 1998, p .252

Tips for Working with Persons with Dementia

• 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

• 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

Promote Safety Communication

Tips for Dementia Care Cont.

• 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

Decrease Confusion

Tips for Dementia Care Cont.

• 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

Physical & Emotional Wellbeing

Family Education

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 ECTDISORDERS DEPRESSIVE

SYMPTOMSCONDITIONS

Severe depression85 – 90%

Anhedonia Tardive dystonia

Treatment-refractorydepression

Anorexia Tardive dyskinesia

Catatonia Delusions Akathisia

Mania Insomnia Parkinsoniansymptoms

Some types ofschizophrenia

Muteness Neurolepticmalignantsyndrome

PsychomotorretardationSuicidal 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 consumption-ischemia

– 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