Dementia & Delirium Eating Disorders Problems of Childhood
and Adolescence Personality Disorders Trisha Economidis Marilee
Elias Fall 2014
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Neurocognitive Disorders Clinically significant cognitive
deficits and changes from previous levels of functioning. Can be
classed as mild or major based on severity of symptoms
Neurocognitive Disorder due to Alzheimers Disease (most common)
Major Neurocognitive Disorder (previously Dementia)
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Other Neurocognitive Disorders Neurocognitive Disorder due to
Parkinsons Disease Neurocognitive Disorder due to HIV Infection
Neurocognitive Disorder due to another medical condition
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Major Neurocognitive D/O & Delirium Common problems of the
Elderly Patient What do we observe? How does it develop? What are
the symptoms? What are the etiologies? What are the
interventions?
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Delirium Characterized by disturbance of consciousness and a
change in cognition (APA) Temporary State of Confusion Develops
rapidly Symptoms CognitionLevel of Consciousness Psychomotor
ActivityEmotions
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Delirium Etiologies: General Medical Conditions
Substance-Induced Substance-Intoxication and/or Withdrawal Multiple
Etiologies
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Delirium Interventions This is an Emergency Aggressive
Treatment Safe Environment Sensory Perceptions Reorient &
reorient & reorient
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Major Neurocognitive Disorder (Previously Dementia) Not a
normal part of Aging Loss of previous levels of cognitive,
executive & memory function Usually Progressive &
Irreversible Classifications Primary Dementias Secondary
Dementias
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Dementia Signs/Symptoms Early stages: progressive memory loss,
trouble finding the right words Symptoms progress with cognitive
decline, increased irritability, loss of sensory & motor
function Late Stages: Unable to recognize family, loses ability to
communicate, forgets how to eat, requires total care
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Interventions with Dementia Orient to reality Clocks, calendars
Promote memory/reminiscing Familiar items, Pictures, Music Provide
safe, structured environment
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Feeding and Eating Disorders Anorexia Nervosa Bulimia
Nervosa
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Anorexia Nervosa Who presents with this disorder? What do they
fear? Whats distorted? What does the patient do about food?
Exercise? What about self-worth? Physical Symptoms?
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Self-worth & Physical Symptoms The self-worths connected to
the symptoms.. Whats up with weight? Whats happening with muscles?
Is it cold in here? What happens to the cardiac system? Yellow
skin, lanugo
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Bulimia Nervosa Whats Bulimia? Whats binging? Whats purging?
What are the physical symptoms? Weight-Exercising Dentition Check
out those hands Cardiac concerns Electrolyte imbalances
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Binge Eating Disorder Eating portions larger than normal Lack
of control over eating At least 3 of the following: 1.Eating more
rapidly 2.Eating until uncomfortably full 3.Eating large amounts
when not hungry 4.Embarrassed by amounts eaten 5.Disgusted,
depressed, guilty after eating
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Etiologies for Anorexia/Bulimia/ Binge Eating Is it in the
genes? Neuroendocrine abnormalities Hypothalamic Dysfunction The
factors of family dysfunction Overprotective, rigid, controlling,
critical parents
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Treatment Modalities Behavior Modification Put the patient in
control, promote autonomy Individual Therapy Family Therapy
Psychopharmacology No specific meds Treat anxiety, depression,
OCD
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Case Study Meet Lily, 14 year old high school freshman. Her
father is Hispanic, and her mother is Caucasian. She identifies
with her fathers Hispanic culture and idolizes the popular Latina
singers.
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Case Study Meet Abby, age 29, her husband Tom, and their 5 year
old daughter Megan. Tom is a young executive in a business firm,
Abby is a stay at home mom. Tom has expectations about how Abby
should care for their daughter and their home.
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Personality Disorders What are they? What are their
characteristics? Often co-exist with? Three clusters of behavior A=
Odd, eccentric B= Dramatic, emotional, or erratic C= Fearful,
Anxious
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Personality Disorders Cluster A Paranoid Schizoid Cluster B
Antisocial Borderline Narcisisstic Histrionic Cluster C
Passive-aggressive
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Paranoid Personality Disorder Cluster A Men> Women Early
adult onset Who do they suspect and mistrust? Hypervigilant and
READY for ALL threats Why do they seek treatment?
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Schizoid Personality Disorder Cluster A Men diagnosed> Women
Pattern of social withdrawal They are way too serious Spontaneity?
Inability to form personal relationships
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Antisocial Personality Disorder Cluster B Men 3X> Women
Exploitative, aggressive & manipulative Lacks a lot Where do we
find them? Lower SEC > Higher SEC (especially in urban
areas)
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Borderline Personality Disorder Cluster B Emotionally unstable,
intense, impulsive, self-destructive, pervasive anger, depressed
The most common personality disorder Women up to 4X > Men Whats
splitting got to do with it? Its all or nothing
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Narcissistic Personality Disorder Cluster B Inalienable right
to special rights & privileges Too much self-worth Men>
Women Exploitive Overly self-centered
Passive/Aggressive Personality Disorder Cluster C Onset by
early adulthood Envy and resent others Negative attitudes Passive
resistance to social, work situations Procrastinate, or forget to
resist Crave attention, reassurance Covertly vent anger and
resentment
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A client with borderline personality disorder has had 21
admissions to the mental health unit, each precipitated by a
suicide attempt, usually resulting in superficial cuts on the arm.
On this admission the client has developed a relationship with a
highly supportive nurse. The client has progressed to having a pass
to spend an afternoon in a nearby shopping mall. The nurse is
shocked when the ED calls to say that the client had just be
brought in with multiple self-inflicted lacerations. The nurse asks
a peer, Why? Everything was going well. How could she do this to
me?
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While the nurse at the personality disorders clinic is
interviewing a client, the client constantly scans the environment
and frequently interrupts to ask what the nurse means by certain
words or phrases. The nurse notes that the client is very sensitive
to the nurses nonverbal behavior. His responses are often
argumentative, sarcastic and hostile. He suggests that he is being
hospitalized so they can exploit me.
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Emotional Problems in Children Behaviors are: Not age
appropriate Deviate from cultural norms Cause deficits or
impairments in adaptive functioning
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Childhood and Adolescent Diagnosis categories
Neurodevelopmental Disorders: Intellectual Disabilities (Previously
Mental Retardation) Autism Spectrum Disorder (new) ADHD Specific
Learning Disorder Motor Disorders (Tourettes Disorder)
Neurodevelopmental Disorders Group of conditions with onset in
the developmental period Typically manifest before child enters
grade school Developmental deficits that produce impairments of
personal, social, academic, or occupational functioning
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Intellectual Disability (Intellectual Development Disorder)
Previously Mental Retardation Must be a current intellectual
deficit as well as a deficit in functioning Onset is in the
developmental period Less emphasis placed on level of IQ and more
on deficits in general mental abilities and functioning May be
classed as Mild, Moderate, Severe or Profound based on adaptive
functioning level NOT IQ
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Intellectual Disability Etiology? Those genes again! Prenatal
factors Pregnancy and perinatal factors General medical conditions
in infancy or childhood Environmental influences and other mental
disorders
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Intellectual Disability Classification based on Adaptive
Functioning Level Mild Moderate Severe Profound Additional
impairments or deficits: Communication, self-care, self-direction,
functional academic skills, work, health, safety and more Adaptive
functioning Able to adapt to daily living requirements? Meet
expectations of persons age or cultural group?
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What are the Interventions? Individualized Plan The 3-Rs
Provide safe, comfortable environment Positive reinforcements Lets
do things in a simple, concrete way Its always a family affair
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Downs Syndrome Most common chromosomal disorder with
developmental delays Prevalence 1/800 live births in the US
Incidence in women > 35 years old Extra chromosome at #21 =
total of 47 Causes changes in both body and brain Mild to moderate
mental retardation
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Autism Spectrum Disorder Previously individual disorders of
Autistic D/O, Aspergers D/O, Childhood Disintegrative Disorder, and
Pervasive Developmental Disorder - now all part of a single
spectrum based on clinical presentation and pathological
findings.
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Autism Spectrum Disorder Determined by impairments in social
interaction and communication across multiple contexts, as well as
restricted, repetitive patterns of behavior, interests or
activities Level of severity is from mild to severe Three levels of
severity for both social communication and restricted
interests/repetitive behaviors used to determine required level of
support
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Attention Deficit/Hyperactivity Disorder A persistent pattern
of inattention and/or hyperactivity and impulsivity that is more
frequent and severe than is typically observed in individuals at a
comparable level of development. ADHD, predominantly inattentive
type ADHD, predominantly hyperactive-impulsive type ADHD, combined
type
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ADHD Etiologies Genes (again?) Biochemical Neurotransmitters
Anatomical Alterations in the brain Prenatal, perinatal, postnatal
factors Environmental factors Psychosocial factors
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ADHD Interventions Provide a safe environment Positive feedback
Develop trusting relationship with caregivers Help child interact
with others at an appropriate level of maturity
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Psychopharmacological Interventions for ADHD Stimulants? Why?
Paradoxical effects of CNS stimulants Hyperactivity Ability to
focus, learn and work What drugs? What can we do to address side
effects?
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Tourettes Syndrome (Motor Disorder) Essential Features? Onset
Before 18 years of age Boys > Girls Etiologies Guess whats first
on the list Biochemical Structural Areas of Brain Dysfunction
Environmental
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Treatment of Tourettes Syndrome Psychosocial Therapy Includes
the Family Psychopharmacological Therapy Drugs Haloperidol
((Haldol)for Severe Symptoms) Pimozide((Orap) Severe Symptoms after
other drug failures) Clonidine (Safe, Few Side Effects) Atypical
Antipsychotics Risperidone (Resperdal) (Good reduction of symptoms)
Ziprasidone (Geodon) Olanzapine (Zyprexa)
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Disruptive, Impulse-Control, and Conduct Disorders Includes
conditions involving problems in the self-control of emotions and
behaviors Manifested in behaviors that violate the rights of others
(aggression, destruction of property) or that bring the individual
into conflict with societal norms or authority figures
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Disruptive, Impulse-Control and Conduct Disorders Symptoms are
severe enough to produce significant impairment: Social Academic
Occupational Conduct Disorder Oppositional Defiant Disorder
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Conduct Disorder What is the pattern of behavior? Whats
violated? Whats common? Behaviors may include aggression to people
or animals (bullying, physical fights), destruction of property,
deceitfulness or theft, and serious violations of rules (running
away, truancy before age 13, staying out at night despite parental
prohibitions before age 13)
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Conduct Disorder Often progresses to Antisocial Personality
Disorder as an adult Predisposing factors: Genetics Biochemical
Diagnosis of ADHD Poor peer relations during childhood Certain
family dynamics: parental rejection, inconsistent or harsh
discipline, large family, marital conflict and divorce, alcohol
abuse in home
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Nursing Interventions Managing Aggressive Behavior Protecting
others from Physical Aggression Improving interactions with others
Developing age-appropriate, acceptable behaviors Client accepting
responsibility for own behavior
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ODD Oppositional Defiant Disorder Whats the pattern of
behavior? Who is the behavior directed against? Impaired
functioning: Social, academic and/or occupational Onset by 8 years
of age Pre-puberty Boys> Girls Puberty more equal Male/Female
ratios
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ODD Etiologies Biological influences Possibly Genetic Family
Influences Parental Problems A power struggle
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Symptoms of ODD Passive-Aggressive Behaviors What will the
child do? Other Physical Manifestations? Enuresis Encopresis
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Nursing Interventions for ODD Compliance with Therapy
Developing less negative attitude Client accepts responsibility for
behaviors Self-esteem Client verbalizes positive self-statements
Improved interactions with staff and peers
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Other Disorders of Childhood/Adolescence: Separation Anxiety
Disorder Now officially classed as an anxiety disorder
Developmentally inappropriate and excessive anxiety concerning
separation from the home or those to whom the person is
attached
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Separation Anxiety Disorder Whats the essential feature? (think
excess) Onset Anytime before 18 years of age As early as preschool
age Girls > Boys
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Separation Anxiety Etiologies You already know the first one
Temperament Environmental Influences Family Influences Stressful
Life Events
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Separation Anxiety Symptoms Difficult separations from who?
Anticipation of separations Refusing to Specific Phobias Depressed
Mood
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Nursing Interventions Provide safe, secure environment Assist
your client to: Reach manageable level of anxiety Develop adequate
coping strategies Spend time away from attachment figure Interact
with others
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Other Disorders of Childhood & Adolescence: Disruptive Mood
Dysregulation Disorder New diagnosis Severe recurrent temper
outburst not in proportion to the situation Verbal and/or physical
rages to people or property, 3 or more times a week. Consistently
irritable or angry, observable by others for 12 or more months;
ages 7-18 yr old. DMDD added because of concerns of over- diagnosis
of bipolar disorder in children Overlaps with ODD criteria, but
more severe
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What treatment modalities do we use for Children and
Adolescents? Behavior Therapy Family Therapy Group Therapy What
kinds? Psychopharmacology Not used as the sole method of
treatment
