1. Gerontological Nursing COGNITIVE AND NEUROLOGICAL FUNCTION Jose Karlo M. Pagan,RN, MAN `WeekNINE

2. CENTRAL NERVOUS SYSTEM (CNS) Brain Spinal CordPERIPHERAL NERVOUS SYSTEM Cranial Nerves Spinal Nerves Somatic NervousSystem Autonomic NervousSystem Reflex Arc 3. NeuronShrinkage in neuron size and gradual decrease in neuron numbers.Structural changes in dendrites.Deposits oflipofuscin granules, neuritic plaque and neurofibrillary bodies within cytoplasm and neuron.Loss of myelin and decreased conduction 4. Changes in precursors necessary for neurotransmitter synthesis.Change in receptor sites.Alteration in enzymes that synthesize and degrade neurotransmittersSignificant decrease in neurotransmitter. 5. MotorMuscular atrophy decrease in muscle bulkDecrease in electrical conduction system 6. Decrease in electrical conductionAtrophy of taste budsAlteration in olfactory nerve fibersAlteration in nerve cells of vestibular system of inner ear, cerebellum, and proprioception. 7. Altered electrical conduction of the nerve due to myelin lossAltered reflexes response (ankle, superficial reflexes 8. Disruption of stage 3 and 4 of the sleep cycle 9. StagesType of Sleep Selected CharacteristicsNON-REM SLEEP (4 STAGES)STAGE 1 LIGHT SLEEP EASILY AWAKENEDSTAGE 2 MEDIUM DEEP SLEEP MORE RELAXEDSLOW EYE MOVEMENTSFRAGMENT DREAMSEASILY AWAKENEDSTAGE 3 MEDIUM DEEP SLEEP RELAXED MUSCLESSLOWED MUSCLEDEC. TEMPAWAKENED BY MOD.STIMULISTAGE 4 DEEP SLEEPRESTORATIVE SLEEPRARE BODY MOVEMENTAWAKENED BY VIGOROUS STIMULIREM ACTIVE SLEEPREMINCREASED OR FLUCTUATING PULSE,BP, RRDREAMING 10. Slowing of autonomic nervous system response as a result of structural changes in basal ganglia. 11. Reduction in the turnover of CSF. 12. Most common mental disorder in the older adults.Between the ages of 80 and 84, 17% of men and 22% of womenhavesevere depression.By age 85, the percentage of older persons with depressive symptoms equalizes.Not a normal consequence of aging.A significant risk for suicide. 13. Changes in feelings or mood,described as feeling sad, hopeless, pessimistic or blue lasting most of the day.Fatigue, constipation, psy chomotor retardation, depressed mood, loss of interest, energy, libido or pleasure, changes in appetite, weight and sleeping pattern. 14. Common response to serious illness of any kind (MS, hypothyroidism, SLE, Hepatitis, AIDS, anem ia)Drugs (Amphetamines, analgesics, narcotics, anti HPN, anti-microbials, anti-Neoplastics, anti- parkinsonian, barbiturates, benzodiazepines, dig oxin, hypoglycemics, phenothizides, steroids, sul fonamides) 15. PSEUDODEMENTIA depression masquerading as DEMENTIAPSEUDODELIRIUM term used when an older adult is seem to be with an acute confusion found to be due to depression. 16. Anti-depressants Trazodone First line of treatment Mild to moderate agitation 25-50 mg SSRI Paroxetine (Paxil), Sertraline (Zoloft), and Fluoxetine (Prozac) agitation. Benzodiazepine reserved for acute conditions Lorazepam (Ativan) 0.25 mg to 1 mg orally or IM Oxazepam 5-10 mg Buspirone anxiety triggered agitation Anti-epileptic Or Anti-convulsants Carbamazepine (tegretol) 4-8 mcg/ml Valproic acid 17. Transient, organic mental syndrome characterized by reduced level of consciousness, reduc ed ability to maintain attention, perceptua l disturbances and memory impairment. 18. ONSET: Short (hours to days)LOCATION: occur in all areas (frequently precipitates hospital admission)RISK FACTORS: Advanced age, CNSdiseases, infection, polypharmacy, GIT, GUT, CPD sensorychanges 19. Medical conditions that causes DeliriumIN THE BRAIN stroke, trauma, meningi tis, and vascular disorder.OUT THE BRAIN endocrine dysfunction, organ failure, infections, meta bolic disorders, shock, burns, dehydration, and nutritional deficiency. 20. MEDICATIONSIN THE BODY opiates, anticholinergic medications, steroids, p sychoactive drugs, OTC cold drug preparations.OUT THE BODY alcohol withdrawal, steroid withdrawal, SSRI withdrawal. 21. Change: Recent onset and fluctuate during the course of the day.Difficulty maintaining concentration or attention to external stimuliLanguage disturbance (slurred, forced or rambling speech)Disorganized thinking (tangenital reasoning and conversation)Disturbances of consciousness.Change in cognition 22. Early assessment Delirium rating scale Delirium symptominterview Identification of riskfactorsDelirium, visualimpairments, severeillness, cognitiveimpairments and highBUN and Creatinine. 23. NON-PHARMACOLOGICINTERVENTION Removing bladder catheters Improving nutritional intake Providing reality orientation PHARMACOLOGIC Decreasing sensoryoverstimulation or deprivationAND NON PHARMACOLOGIC Reassuring the older adult andhis or her family members.INTERVENTIONS PHARMACOLOGIC Agitations and hallucination Haloperidol Alcohol withdrawal symptoms benzodiazepines 24. Is a syndrome of gradual and progressive cognitive declineAlteration in memoryCharacterized by a loss of cognition and at least one of the following Ability to speak coherently and understand language (APHASIA) Ability to recognize or identify objects (AGNOSIA) Ability to execute motor activities (APRAXIA) Ability to think abstractly, make sound judgment, and plan and carry out complex tasks 25. Phenomenon that occurs when other pathologic condition masquerade as dementia.Medications, ethyl alcohol intoxication or withdrawal, metabolic disorders (thyroid disorders, Vitamin B12, hyponatremia, hypercalcemi a, hepatic and renal dysfunction) depression, delirium, CNS neoplasms, chronic subdural hematoma, normal pressure hydrocephalus. 26. Progressive neurodegenerative disease characterized by the presence of neurofibrillary tangles composed of misplaced proteins within the brain, cortical amyloid plaques, and granulovascular degeneration of neurons in the pyramidal cell layer of the hippocampus. 27. GeneticsViralAgeHead injuryEnvironmental exposuresNutritional factors 28. Individuals repeated questions and statementsForgetfulnessIncreasing problem with orientation and geographic disorientationMemory lossLanguage deteriorationImpaired ability to mentally manipulate visual informationPoor judgmentConfusionRestlessnessMood swingsPersonality changes 29. MRIPET 30. No cure for ADCognex Cholinesterase inhibitors Monitor the patients liverDonepezil (Aricept)RivastigmineGalantamine (Reminyl)Gingko Biloba herbal plant extract Enhances the cognitive performance Vitamin supplementation 31. Preserving the dignity and promoting independenceMaintaining the cognitive and global function early in the disease process. 32. Loss of cognitive function resulting from ischemic, hypoperfusive or hemorrhagic brain lesions from a CVDAbrupt onset of dementiaMulti infarct dementia (Multiple strokes in CT or MRI present)Focal neurological findingsLow-density areas indicate vascular changes in white matterUnchanged personalityEmotional problem 33. Arteriosclerosis, blood dyscrasias, cardiac decompensation, hypert ension, atrial fibrillation, cardiac valve replacement, systemic emboli. 34. Symptoms depends on the location of the infarct Impaired learning and impaired retention of new information Impaired handling new tasks Impaired reasoning ability Impaired spatial ability and orientation Impaired language. 35. CT Scan and MRI 36. Donepezil improving cognition and function, clinical global impression and ability to perform ADLs.Nimodipine short term benefit for VAD 37. Clinical features persist over longperiod of time resulting in severedementia Lewy bodies and Lewy neuritis foundin brain structures Found in theLewybrainstem, diencephalon, basalganglia and cerebral cortexbody Lewy bodies : are abnormal dementiaaggregates of protein that developinside nerve cells in Parkinsonsdisease (PD) and Alzheimers disease(AD) and some other disorders. 38. advanced ageDepressionconfusion or psychosis while taking levodopa,facial masking of individuals with PD 39. Prominent fluctuations in attention and ability to communicate.More visual-spatial processing impairments andClinical subcortical dementia. manifestations:EPS: rigidity, bradykinesia,flexed posture, shuffling gait. 40. Symptomatic reliefCholinesteraseMANAGEMENT: inhibitors 41. Presence of frontal brain Fronto-temporal area atrophy in lobe dementia CT or MRI 42. Clinical Manifestations: Frontal or aphasicvariants changes inpersonality and socialcognition, disinhibitions, loss of Diagnostics CTempathy, changes inscan or MRIeatingpattern, stereotypicbehavior. Fluent or non fluentaphasia. 43. Management 3-10 years No specifictreatment 44. Assessment Glasgow comascale Mental statusexamination Pupilexamination Neurologicassessment Behavioralassessment 45. Individualized care for each patientsMonitor and maintain physical healthAdapt the environmentCommunicate in a simple, direct mannerProvide cues for reality orientationMaintain social interaction and self esteem. 46. Sundowning syndromeWanderingParanoia and suspiciousnessHallucinations and DelusionsCatastrophic ReactionsResources 47. Primary cause: UnknownOther causes: viral infection, disequilib rium between dopamine and acetylcholine, ence phalitis, arterioscler osis, and carbon monoxide poisoning, stroke, i nfections. 48. Tremors pillrolling tremors Resting tremorsCogwheel rigidityBradykinesia, AkinesiaPropulsive gait ( begins walking, then starts running forward unable to stop until he or she falls or runs into something.)Festinating gait ( small steps)Retropulsion ( walking and falling backward) 49. Freezing (a phenomenon where the individual appears to be glued to the floor.)Mask like facial expression (flat affect)Emotional lability, depressionFatigueSoft, monotonous voiceShaky small handwritingExcessive sweating, seborrhea, lacri mation, constipation, decre ased sexual activity. 50. Diagnostics EEG Symptomsimprove withantiparkinsoniandrugs 51. Aimed: relieving clinical manifestations, increasing individuals ability to perform ADLs and decreasing the risk for injury.MEDICATIONS Anticholinergics Cogentin (Benztropine) Akineton (Biperiden) Artane (Trihexyphenidyl) MAO Dopaminergics 52. Monitor v/s, urine output andbowel sounds Observe for involuntarymovements Advise the client to avoid Nursingalcohol, cigarette, caffeine andaspirin.Intervention for Prevent and relieve side effects: the Dry mouth : hard candy, icepharmacologicchips, sugarless chewing gum Photophobia: sunglassesmanagement: Urinary retention: void beforetaking the drug Increased intraocular pressure:routine eye examinations 53. Levodopa Carbidopa with Levodopa (Sinemet) Nursing Interventions: Side effect: Orthostatic Hypotension Monitor clients vital signs and ECG Check for weakness, dizziness orsyncope. Advise the client to practicegradual change of position. Reddish brown urine andperspiration Harmless but clothes may bestained. Impaired voluntary movement takes weeks or months to becontrolled. 54. Symmetrel (Amantadine HCL) -dopaminergic Parlodel (BromocriptineMesylate) Requip (Ropinizole HCL) Nursing Interventions: Report signs of skinlesion, seizure or depression. Report lightedness whenchanging positions. Avoid alcohol Advise the client not toabruptly stop the drugwithout notifying the healthcare provider. 55. Ablation (destruction)Deep brain stimulationTransplantation 56. Provide a safeenvironment Provide measures toincrease mobility: Physical therapy, Assistive devices Encourage independencein self care activities. Improve communicationabilities. Maintain AdequateNutrition Avoid constipation andmaintain adequate bowelelimination. 57. VisionLose of tone of the eye lids and become lax ptosis of the eyelids, redundancy of the skin, and malposition of the eyelids.Conjunctiva thins and yellow in appearance. 58. Sclera develop brown spots Arcus senilis surrounding rings made up of fat deposits at the cornea. Pupil decrease in size and loses some of its ability to constrict. Limit the amount of light entering the eye.Lens increases in rigidity and density affecting the eyes ability to transmit and focus light. 59. Peripheral vision decreases, night vision diminishes and sensitivity to glare increases.Difficulty in identifying cool colors: blue, green and violet.Vitreous humor loses transparency and increases the scattering of light. (causes Floaters- dots, wigly lines or clouds)Flashers jagged lines; vit. Fluid rubs eyes or pulls retina. 60. Decline in the visual acuityPresbyopia inability to focus nearby objects. 61. Group of degenerative eye diseases in which the optic nerve is damaged by high intraocular pressure (IOP) resulting in blindness due to nerve atrophy. 62. Race (African Americans, Asian American and Alaska Natives)eye traumasmall corneasmall anterior chamberFamily historyCataractsSome Medications 63. Cause: Unknown, results from a papillary blockage that limits the flow of aqueous humor causing an increase in IOP. 64. More common, occurs gradually.90% of all primary glaucomaDegenerative changes in Schlemms canal obstruct the escape of aqueous humor. 65. Peripheral vision loss gradually and painlesslyTired eyesSeing Halos around lightsWorse symptoms experience in the morning. 66. Symptoms associated with StressMedical emergency and the patient should seek emergency help immediately.Severe eye pain in one eyered eyeBlurred visionNausea and VomitingSeeing colored halos around the lightsBradycardiaPupil dilationSteamy appearance of cornea 67. When drainage angle is damage by eye injury or other specific conditions.Medications (steroids), tumors, in flammation, or abnormal blood vessels. 68. Diagnosis: Gonioscopy direct exam Tonometer to measureIOP (Normal :10-21 mmHg) 69. Aimed to reduce IOP.MedicationsSurgery: Iridectomy for AcuteGlaucoma Treatment TrabeculoplastyChronic Glaucoma Medications and eyedropsConcern: Safety 70. Medical follow-up and eye medicationwill be required for the rest of your life. Eyedrops must be continued as long asprescribed, even the absence ofsymptoms Avoid driving 1-2 hours after theadministration of miotics Prevent complications Bright lights and darkness are notharmful There is no apparent relationshipbetween the vascular hypertension andocular hypertension. Report any reappearance of symptoms Avoid the use of mydriatric or cyclopegicdrugs. (atropine) 71. Clouding of the normally clear and transparent lens of the eyes.Cause by Oxidative damage to lens proteins that occurs with aging. Other causes: Heredity diabetes poor nutrition hypertension excessive exposure to sunlight cigarette smoking high alcohol intake Eye trauma. 72. Senile Cataract due to normal aging process as early as 40Traumatic CataractTypes of hardCataract blow, puncture, cut or burn.Secondary 73. With gradual loss of vision (blurred, misty or dimmed) Complaints of being fuzzy, sensitive to glare and halo-effect around lights.No pain or discomfortDecrease night visionYellowing of the lens.trouble distinguishing colorsPupil changed into cloudy white.Decreased visual acuity.Recurrent eyeglass prescription changes. 74. Improved visual acuity, depth perception.Complications: Surgery retinal detachment, in fection and macular edema. 75. Avoid rubbing or pressing on the eye.Avoid bending at the waist or lifting heavy objects for at least 1 ACTIVITIES monthNOT TO DOAvoid straining with AFTER A bowel movementsCATARACTAvoid taking showersSURGERY and shampooing hair for specified time as instructed.Limit reading. 76. Sleep on back or unaffected side.Apply metal eye shield at night.Wear glasses indoorsProper handwashing 77. Most common cause of blindness for those over age 60.Damage or breakdown of the macula and subsequent loss of central vision due to Macular Degeneration. 78. Dry (Nonexudative) involutional macular degeneration. Breaking down or thinningof macular tissue related tothe aging process. Types: Gradual vision loss.Wet (exudative) rapid and severe vision loss. Abnormal blood vesselsform and hemorrhage. 79. Difficulty performing tasks (reading and sewing)Decreased central visionSeeing images are Signs and distortedSymptoms:Decreased color vision (colors look dim)Central Scotoma (sometimes) 80. Photodynamic Therapy a special laser to seal leaking blood vessels.Retinal Cell TransplantationMedications:Treatment Ranibizumab (Lucentis) Bevacizumaba Pegaptanib 81. Auricle becomes elongated, with a wrinkled appearance.Auditory canals narrowsHairs lining the canal becomes coarser and stiffer.Cerumen glands atrophyTympanic membrane dull, retracted and gray appearance.Degeneration of the ossicular joints in the middle earDecreased vestibular sensitivity. 82. Age related balance declineDecreased sensory input, slowing of motor responses and musculoskeletal limitations. 83. Reversible, overlooked cause of conductive hearing loss.Cause: physiologic changes with aging atrophic changes in theCerumen sebaceous and apocrineImpaction glands.Impaired communication social isolation and depression. 84. Hearingloss, feeling offullness in theear, itching andtinnitus.Intervention Read theprotocol forcerumenremoval page740 85. Is the annoying combination of both conductive and sensorineural hearing loss.Subjective sensation in the ear, defined as the ringing, buzzing or hissing.Cause: noise, toxins, cochlear nerve and age related changes in the organs of hearing. 86. SubjectiveObjective rareUnilateral associated with more serious diseases (Menieres disease) 87. Treat the correctable problems.Softening loud sounds through improved acousticUse a protective ear plugsAvoid ototoxic substances (foods, drugs) 88. sensorineural hearing lossThe most common form of hearing loss in older adult.Bilateral, difficulty hearing high pitched tones and conversational speech. 89. Increasing volume on television or radio.Tilting head toward the person speakingCupping hand around the ear.Watching the speakers lipsSpeaking loudlyNot responding when spoken to 90. Focus on aural rehabilitation and facilitation of communication.Aural rehabilitationAuditory trainingspeech and reading traininghearing aids. 91. should not be considered as a normal part of aging.Benign paroxysmal positional vertigo (BPPV) severe episodes of vertigo precipitated by a particular change in head position.Ampullary dysequilibrium vertigo or disequilibrium associated with rotational head movements. 92. Macular disequilibrium vertigo precipitated by a change of head position in relation to the direction of gravitational force.Vesicular ataxia of aging constant feeling of imbalance with ambulation.Menieres disease an uncommon disease seen most often in older women, characterized with severe vertigo accompanied and usually preceded by tinnitus and progressive low frequency sensorineural hearing loss. 93. Pharmacological treatment Anti-vertiginous drugsMeclizine (antivert)Diphenhydramine (Benadryl) May causedrowsiness, avoid alcoholicbeveragesDiuretic Hydrochlorothiazide(Hydrodiuril)Remove the excessendolymph fluid 94. No complete cureMeasures to reduce dizziness Move slowly Avoid bright glaring Nursinglights (quiet darkened interventionsroom is preferred) For Vertigo If vertigo occursduring ambulation liedown immediatelyand hold the headstill.