Chapter 18: Neurocognitive Disorders

Welcome back to the deep dive today we are we're wading into waters that I think every single person listening has feared at some point we're talking about the mind specifically we're looking at what happens when the mind the very thing that makes you who you are starts to fail it really is the ultimate existential fear isn't it I mean if I lose my memories if I lose my ability to process the world around me what is actually left of my identity exactly and you know we aren't just philosophizing today we are taking a very rigorous look at chapter 18 of essentials of psychiatric mental health nursing the fourth edition we're tackling neurocognitive disorders and I want to set the straights right off the bat for you if you are nursing student this chapter is literally the difference between a patient feeling safe in your care or feeling like they are trapped in a waking nightmare that is not an exaggeration at all the source material makes it incredibly clear right from the jump cognition is the operating system it's not just doing math and remembering a grocery list it is the complex integration of acquiring knowledge reasoning memory and judgment right it's how you know that the person standing next to your bed is a nurse and not an intruder it's how you know that the urge in your bladder means you need to walk to the bathroom not the closet precisely and when that operating system crashes the results are catastrophic so we have a massive amount of ground to cover today we're going to explore the three giant buckets provided in the text delirium mild neurocognitive disorders and the big one major neurocognitive disorders with a specific focus on alzheimer's disease yeah we are going to pull apart the biology really get into the weeds of plaques and tangles the pharmacology and most importantly the nursing interventions because as the text points out you are the front line you're the eyes and ears you're the one who notices that mrs.

Jones was you know totally fine at breakfast but is suddenly talking to invisible people by lunch and that sudden change is exactly where we need to start that first bucket delirium the sudden storm right

delirium is a word that gets misused constantly in pop culture people think it just means really excited or feverish but clinically delirium is a medical emergency the text defines it as a disturbance and attention and awareness and a change in cognition that develops over a short period of time a short period of time being the key phrase there right crucial we're talking hours to days this isn't the slow agonizing fate of dementia this is a cliff one minute you're on solid ground the next year in freefall and the most important takeaway from the entire section on delirium is this is always secondary to another physiological condition meaning the brain isn't broken because the brain itself is diseased the brain is malfunctioning because something else in the body is poisoning it or stressing it out yes exactly it's a symptom it's the smoke alarm going off but the fire is somewhere else it could be an infection it could be a reaction to a new medication it could be withdrawal the good news and the text emphasizes this heavily is that if you treat the underlying cause the delirium usually resolves it is reversible which is a massive distinction from what we'll talk about later with dementia but before we get into the causes of that fire I was honestly shocked by the prevalence numbers in the source material I think most people assume delirium is rare it is anything but rare the text sites that delirium is present in up to 60 percent of nursing home residents who are age 75 or older but look at the hospital numbers post -surgical older adults up to 53 percent over half so if you have a grandparent going in for a hip replacement there is a coin flip chance they'll experience this yeah and if you go into the intensive care unit the ICU the numbers are just staggering depending on the study anywhere from 70 percent to 87 percent of older adults in the ICU develop delirium wow that's almost everyone if you have an older relative in the ICU you should almost expect this to happen you absolutely should and the problem is it often goes unrecognized the text mentions that because the symptoms fluctuate like a patient might be lucid when the doctor rounds in the morning but completely confused at 2 p .m.

it gets missed and missed delirium is incredibly dangerous it's linked to longer hospital stays higher rates of permanent institutionalization and increased mortality so let's paint the picture for the listener you're a nurse you walk into a room what are you seeing what is delirium actually look like in real time well the hallmark is the inability to focus or sustain attention you ask them a question and they're mine just slides right off of it they might be picking at the bedsheets that's a very common physical sign like restless picking their speech might be rambling or incoherent but the most terrifying part for the patient involves the perceptual disturbances and this is where we get into illusions and hallucinations the text makes a really specific distinction between these two and I think it's important to understand the difference because how you handle them is different it is so let's start with an illusion an illusion is a misinterpretation of a real sensory experience okay give me a concrete example from a hospital room let's say there is an electrical cord for the blinds lying on the floor it's really there but the patient looks at it and their brain misfires they don't see a cord they see a snake coiled up and ready to strike the input is real the cord but the output the snake is completely wrong and the text says that with illusions you can often clarify reality for them sometimes yes you can pick up the cord carefully and show them say look mr.

Smith it's just the plastic cord for the blinds and sometimes that registers their brain can recalibrate for a moment but a hallucination is a totally different beast a hallucination is a false sensory perception with no external stimulus whatsoever the brain is just making it up entirely there's nothing there nothing and in delirium these are usually visual or tactile they see giant spiders crawling on the bedsheets they feel bugs burrowing under their skin it is literally a waking nightmare there's a vignette in the text that I want to spend some time on because I think it perfectly illustrates how terrifying this is from the patient's perspective and how easily medical staff can inadvertently make it worse the story of mr.

Arnold ah mr.

Arnold this is a classic tragic case of ICU delirium so let's set the scene mr.

Arnold is 55 he's recovering from a triple bypass heart surgery he's in the ICU and he's waking up from anesthesia yeah put yourself in his brain for a second okay my chest feels like it's been sawed open I'm groggy they're machines beeping everywhere I have no idea where I am right and your brain is inflamed from the major surgery you are likely on heavy painkillers your oxygen levels might be fluctuating and mr.

Arnold hears the nurses talking at the station one nurse says to another I need to get a gas on mr.

Arnold a blood gas arterial blood gas a very routine test where they draw blood from the artery to check oxygen routine for the nurse sure but mr.

Arnold's brain drops the word blood he just hears get a gas on mr.

Arnold then another nurse says you want me to use a large needle for the injection oh no I see exactly where this is going mr.

Arnold's paranoid delirious brain connects these dots gas needle injection he concludes they are going to execute him that is a completely logical leap if your operating system is glitching he thinks he's on death row it's a terrified logic so his survival instinct kicks in he needs to escape he needs to pee but he has a catheter in the nurse tells him you can't get up you have a tube in she says keep your mask on she means the oxygen mask he thinks it's the gas mask for his execution it's like a horror movie script but it's his actual reality it is he looks around and sees an exit sign that exit sign is an illusion to him he interprets it as is only portal to safety the nurse sees he's agitated and tries to reassure him by taking off his wrist restraints she thinks she's being kind but to him she just untied the victim exactly so he bolts he runs down the hall barricades himself in a room he pulls out his chest tube he pulls out his catheter which causes massive physical trauma we're talking severe bleeding potential lung collapse from the chest tube removal massive trauma security has to physically break down the door it's a complete disaster and it all stem from a failure to communicate clearly and a failure to recognize his delirium so if we look at that scenario what should be nurses have done differently how do we stop the horror movie before it starts first recognize the risk he's post -op he's in the ICU he is incredibly high risk for delirium second communication don't use medical jargon don't say gas walk in introduce yourself hi mr.

Arnold I'm Sarah your nurse you are in the hospital you had heart surgery you are safe orient him repeatedly it seems so simple but in the rush to the ICU I can totally see how it gets skipped you get skipped all the time yeah and that brings us to the causes because if we see this confusion happening we have to play detective we have to find the underlying cause and the text gives us a great tool for this the mind space is mnemonic I love a good mnemonic but this is a long one looks to break it down because this is effectively a diagnostic checklist for any nurse dealing with a confused patient it is let's go letter by letter M is for medications this is the big offender polypharmacy taking too many drugs that interact or specific drugs that are toxic to older brains the text specifically references the beers criteria which sounds like a public hubcrawl list but definitely isn't definitely not the beers criteria is a list of medications that are potentially inappropriate for older adults drugs like benadryl certain sedatives anti cholinergics they can flip a switch in an older brain and cause instant confusion okay moving on and attacked is for infection urinary tract infections UTIs and pneumonia this is a huge one if your grandma suddenly goes crazy talking nonsense becoming aggressive check her urine it is the classic presentation of a UTI in the elderly they often don't even get a fever they just get delirious that is such a crucial nugget for nursing practice if the behavior suddenly changes check for infection N is for number of comorbidities right if you have heart failure diabetes and COPD your physiological reserve is low you just have less buffer before your brain tips over into dysfunction D is disorders of substance use withdrawal alcohol withdrawal delirium tremens is a massive medical emergency if a patient is an alcoholic and suddenly stops drinking because they're admitted to the hospital 48 to 72 hours later they can go into severe delirium it can literally be fatal S is for surgery we saw that with mr.

Arnold anesthesia is really tough on the brain orthopedic surgery cardiac surgery those are particularly high risk P is pain or perfusion uncontrolled pain drives people into delirium but so does perfusion meaning blood flow if your blood pressure drops or your oxygen drops the brain starves confusion is actually a late sign of brain starvation T is age the very young and the very old are most susceptible because their blood brain barriers are structurally different C is cognitive impairment this is the cruel irony if you already have dementia you're much more likely to get delirium on top of it we call it delirium superimposed on dementia it makes their baseline confusion suddenly much much worse B is emotional illness severe depression or mania can sometimes manifest as acute delirious states and finally S for sleep sleep disturbances sleep deprivation in the hospital is a major contributor in the ICU the lights are on 24 7 alarms are constantly beeping if you don't sleep for three days you will hallucinate it happens to perfectly healthy people let alone sick ones so we have the causes we know what it looks like now let's talk about the nursing process how do we formally assess it the text mentions the cam the confusion assessment method it's a validated screening tool it basically asks for core questions one is the onset acute and fluctuating two is there inattention three is thinking disorganized and four is the level of consciousness altered if you have one in two plus either three or four you have delirium and once we identify it safety is the absolute priority the text is very strict here it says a patient in acute delirium should never be left alone that is the golden rule but here's the reality check for nursing students nurses have five six seven patients at a time they cannot sit in one room for a 12 -hour shift this is where sitters come in staff specifically designated to just watch the patient

and the text strongly advises against relying solely on family for this why is that because family seems like the best option they know the patient they can calm them down they provide great emotional support yes but they aren't trained to handle a 200 pound man ripping out a central line it's a safety liability you need trained staff who know how to deescalate and if absolutely necessary restrain physically or chemically though we always try to avoid restraints because they just increase the fear right imagine mr.

Arnold again if you tie him down you're just confirming his delusion that he's been kidnapped exactly so other interventions are environmental put the glasses on the patient put their hearing aids in if the world is blurry and muffled it is terrifying shadows look like monsters ensure good lighting clear clocks visible calendars you have to anchor them to reality before we move on from delirium I want to clarify the big three nurses often get delirium dementia and depression mixed up because they all look like confusion or withdrawal on the surface table 18 .3 breaks this down beautifully it's a vital differential diagnosis so let's look at onset delirium is sudden hours or days dementia is slow months or years depression is usually gradual or triggered by a specific life event what about level of consciousness in delirium they are drifting they go from stuporous to hyper alert in dementia and depression they're generally fully awake and alert just confused or sad and reversibility delirium is reversible depression is reversible dementia is generally progressive and irreversible okay that is the acute storm now let's transition to the chronic conditions the neurocognitive disorders the text divides these into mild major what is the actual line in the sand between them independence that is the core dsm five criteria distinction in a mild neurocognitive disorder the person has modest impairment maybe they struggle with really complex math where they need to start making lists to remember appointments but and this is the key they can still pay their own bills they can still feed themselves they are independent and major in major neurocognitive disorder which is the clinical term the dsm five uses for dementia the impairment is severe enough that it does interfere with daily independence they cannot manage life alone anymore the text also mentions mci mild cognitive impairment is that the same thing as mild ncd it's a bit of a gray area mci is a syndrome not yet formally in the dsm five but it's crucial it's often considered a precursor it's like the waiting room people with mci have memory slips that are worse than normal aging but they aren't fully impaired yet but the statistics show they're at a very high risk of progressing to alzheimer's which brings us to the giant in the room the exemplar for this chapter alzheimer's disease it accounts for 60 to 90 percent of all dementias it's a massive public health crisis and unlike delirium it is a primary neurocognitive disorder it's not a side effect of a uti it is the disease itself and it is progressive and irreversible i think everyone listening has a deep fear of this you forget where you put your keys one morning and you think is this it is it starting so let's look at the risk factors what actually puts you at risk the biggest one unfortunately is simply surviving age the risk doubles every five years after age 65 by the time you reach 85 nearly half the population has some form of ncd that is a staggering statistic it almost makes it sound like if you live long enough it inevitably comes for you it feels that way but the text is emphatic about this yeah alzheimer's is not a normal part of aging it is a specific pathology it's a disease process then there's genetics we had the apo e gene specifically the e4 allele if you inherit one copy from a parent your risk is three times higher if you get two copies your risk is 12 times higher but having the gene isn't an absolute guarantee no not at all you can have the genes and never get it you can have no genes and still get it the only truly genetic forms are the rare early onset types familial alzheimer's that strike people in their 30s 40s and 50s those are linked to specific mutations like app ps1 and ps2 if you have those mutations you will almost certainly get the disease but that is less than 1 % of all cases the text also brings up a fascinating link between the heart and the head what's good for the heart is good for the brain the brain is an incredibly greedy organ it uses 20 % of your blood flow if your vessels are clogged with cholesterol or damaged by high blood pressure or inflamed by diabetes the brain suffers small strokes micro damage these accumulate over decades and drastically lower the brain's resilience to alzheimer's there's also a specific note on head trauma yes boxers football players dramatic brain injury or tbi increases the risk significantly and let's touch on the cultural considerations because the text highlights some disparities that are really important for nurses to be aware of african -americans and hispanics have higher rates of alzheimer's than whites but the text explicitly warns us not to misinterpret this as purely genetic it is highly likely driven by socioeconomic factors higher rates of hypertension higher rates of diabetes less access to preventive health care over a lifetime it ties right back into the comorbidity burden we talked about earlier okay we are going to go deep into the biology now i want to visualize this what is physically destroying the brain in alzheimer's the text mentions plaques and tangles we hear those words a lot in the media but what are they actually to understand this let's use an analogy imagine the brain is a massive bustling city the neurons are the houses where the people live and work the spaces between the neurons are the streets and highways where messages travel back and forth first we have the amyloid cascade hypothesis beta amyloid is a sticky starchy protein snippet in a healthy brain it gets cleared away naturally like trash garbage trucks come by and pick it up exactly but in all timers the trash trucks stop working this protein clumps together outside the neurons in the streets the plaques right these are the plaques they are like massive piles of rubble blocking the roads they physically interfere with the chemical signals passing between neurons but it's actually worse than just a physical blockade they also trigger massive inflammation the body's immune system sees these piles of rubble and attacks them causing severe collateral damage to the healthy cells nearby so the roads are blocked and there's a riot happening in the street what about the tangles the tangles happen inside the house inside the neuron itself neurons have a structural skeleton a transport system made of microtubules think of them as railroad tracks that carry essential nutrients from the center of the cell all the way out to the edges a protein called tau acts as the railroad ties it holds the tracks together okay so tau is the glue or the bolts keeping the track stable correct in all timers the tau protein chemically changes it gets twisted it lets go of the tracks so the railroad tracks collapse into integrate the nutrient train can't run anymore and that tau clumps together into what we call neurofibrillary tangles and without the train bringing food the cell starves and dies exactly so we have rubble in the streets the plaques blocking communication and collapsing infrastructure inside the houses the tangles killing the residents that is a perfect analogy and the third component of this biological breakdown is the cholinergic hypothesis because all these cells are dying the brain stops producing acetylcholine which is the primary neurotransmitter for memory and learning it's the vital chemical messenger so the message can't get through the messenger is dead and the roads are blocked it's a total infrastructure collapse it really is and the result physically is atrophy if you look at an MRI of an advanced Alzheimer's brain it is literally shrunken the cortex the thinking planning part shrivels up the hippocampus the memory center is completely decimated the ventricles the fluid filled holes in the middle of the brain gets huge because all the brain tissue around them has simply vanished it's horrifyingly destructive now how does this biological collapse manifest in a human life the text uses the vignette of Mr.

Collins the telephone lineman to walk us through the four stages I think following his story makes this abstract microscopic tragedy very concrete let's follow Mr.

Collins stage one is mild Alzheimer's the forgetfulness page Mr.

Collins is 60 he's working as a lineman which is a highly complex job requiring memory and strict safety protocols he starts losing things keys his wallet normal stuff right but then at work he momentarily forgets the color codes for the utility wires that's muscle memory for alignment that is a massive red flag it is he connects a ground wire to a hot wire he causes a massive outage his supervisors are furious but Mr.

Collins doesn't say hey I'm confused he gets defensive he says the schematics were wrong this is the key feature of stage one denial the person knows something is slipping and they are terrified so they cover it up they use humor they use anger they rationalize he's desperately trying to hold the facade together he doesn't want to lose his job his identity yes but eventually the biology wins the facade cracks we move to stage two moderate Alzheimer's the confusion stage the memory loss is no longer just where my keys it's what is my home address Mr.

Collins starts withdrawing from social events because he can't follow the speed of the conversation anymore we start seeing a praxia he can't manipulate common objects he tries to zip his pants and can't figure out the mechanism he puts his shirt on backward and the personality changes really kick in here too this is where it gets incredibly hard for the family the text mentions paranoia Mr.

Collins starts thinking his supervisor spying on him to the living room window he thinks people are stealing his money and we see sundown as the sun goes down the confusion gets markedly worse he starts pacing wandering becomes a serious risk he can no longer drive safely he can no longer live alone without significant support then we hit stage three moderate to severe the text calls this ambulatory dementia this is the heartbreak stage Mr.

Collins looks at his wife of 40 years and sees a total stranger that is agnosia the complete loss of sensory recognition he wanders aimlessly he becomes incontinent he loses bladder and bowel control the text describes this as the stage where institutional care is usually required the physical demands on the family cleaning feeding watching him 24 -7 to prevent him walking out into traffic it simply breaks the family it is too much for one person to manage and finally stage four late or end stage the world has shrunk to the immediate sensory experience Mr.

Collins stops walking he stops talking he forgets how to eat we see the return of infantile reflexes hyperorality he tries to put everything in his mouth just like a baby hypermetamorphosis he feels an uncontrollable compulsion to touch everything in reach eventually he forgets how to swallow and death usually comes not from the brain itself shutting down the heart but from aspirational pneumonia or infection the body just gives out in the vignette Mr.

Collins dies in a VA hospital he doesn't know his wife anymore but the text makes a beautiful note that when music played he would tap his foot it shows that deep down below the cognitive ruin the rhythm of the human spirit the emotional memory is often the very last thing to go so we have the trajectory now put ourselves in the shoes of the nurse we are caring for Mr.

Collins or someone like him how do we assess him the text gives us the four A's of cognitive impairment we touched on them but let's define them clearly for the students listening so they have them locked in for their exams these are the pillars of dementia assessment one amnesia memory loss two aphasia loss of language ability it usually starts with an omnia meaning I can't find the word progresses to babbling and ends with complete mutism three is apraxia loss of purposeful movement you hand them a comb and they try to brush their teeth with it the motor signal from the brain to the hand is complete completely scrambled and four agnosia loss of sensory recognition they hear a doorbell ring but they don't know it means someone is at the door they see a chair but they don't know it's an object meant for sitting and while assessing we need to watch for the defense mechanisms because even in the profound confusion the ego is still trying to protect itself right confabulation is a big one you ask a patient Mr.

Jones what you have for breakfast he doesn't remember but his brain cannot handle the void of that missing information so he says I had eggs benedict with the queen of England and it's so important to stress here he isn't lying to you no he's lying at all lying is a conscious calculated choice to deceive confabulation is an unconscious attempt to fill the gap and maintain self -esteem he absolutely believes his own story in that moment and the second defense mechanism is perseveration the broken record repeating a word or phrase over and over again I want to go home I want to go home I want to go home usually means they are highly stressed and their brain is stuck in a loop

it's often a sign they're trying to communicate an unmet need but can't find the other words to express it for diagnostic tests the text mentions the MMSE the mini mental state exam and the mocha but I really like the mini cog the clock drawing test it is deceptively simple you ask the patient draw a clock face put all the numbers in now set the hands to 10 past 11 to do that successfully you need language comprehension to understand the command spatial planning to draw the circle memory to know where the numbers go and find motor control if the circle is squiggly or the numbers are all crowded onto one side which suggests visual neglect or the hands are just drawn wrong it tells you a massive amount about the brain's executive function in about 45 seconds and we absolutely have to rule out mimics before diagnosing dementia the text mentions pseudo dementia this is critical for nurses to look out for severe depression in the elderly can look exactly like dementia they're forgetful they move slowly they are completely apathetic they just say I don't know to every question but if you treat the depression with antidepressants and therapy the memory actually comes back that's why you never just assume it's Alzheimer's without fully screening for depression first let's move to the art of nursing the communication aspect this is where I think this chapter is honestly most beautiful the text talks about unconditional positive regard it means we don't argue with their reality we accept them exactly where they are there's a massive debate in nursing reality orientation versus validation therapy reality orientation being mr.

Smith it is Tuesday you are in the hospital which is perfectly fine for delirium or early stage dementia but for moderate to severe dementia it can be intensely cruel imagine a 90 year old woman mrs.

Higgins she is crying hysterically because she wants her mother if you use reality orientation you say mrs.

Higgins you are 90 years old your mother died 40 years ago what does she do she screams she mourns as if hearing it for the first time you have just profoundly traumatized her and because she has no short -term memory 10 minutes later she will ask for her mother again and you will traumatize her again it's a literal torture loop that sounds horrible so we use validation therapy instead yes you validate the emotion not the fact she says I want my mother you say you're feeling lonely and you really miss your mom she was a wonderful lady wasn't she what is she used to bake for you you step into her time machine you connect with the feeling of love and safety she is desperately craving she calms down because she feels heard and validated there is a vignette in the text about a student nurse and mr.

Sampson that illustrates this failure perfectly oh it's painful to read mr.

Sampson is 75 his wife darlin died three weeks ago he is pacing the nursing home lobby crying asking why isn't she here where is she the student nurse trying to be honest and orient him brings him a photo of her funeral she shows him the casket it's like hitting him with a physical hammer he collapses oh god she died how can i go on the massive catastrophic reaction but the student realizes her mistake she sees that the objective truth isn't the priority here comfort is so she shifts gears she sits with him she asked permission to hold his hand touches very very powerful she asked about the older photos in his wallet tell me about this garden he starts talking about darlin's tomatoes he smiles the grief is still there but the raw panic is gone that is reminiscence therapy it honors the person's history that is such a powerful lesson we are curators of their peace not just enforcers of the truth now let's talk about the practical application safety and milieu because these patients wander they are notorious escape artists they really are 60 percent of alzheimer's patients wander it's incredibly dangerous the text suggests medical or bracelets immediately upon diagnosis in the home you essentially have to outsmart the damaged brain patients with dementia lose their peripheral vision and their ability to scan an environment they tend to just look straight down so put the deadbolts on the doors at the very top or at the very bottom they literally won't see them or cover the door knob yes cover the knob with a piece of cloth sometimes just masking the visual cue of the knob breaks the mental connection of turn this to open and if they are climbing out of bed and risking a fall put the mattress directly on the floor it is much better to roll onto the floor than to fall three feet and shatter a hip what about problematic or aggressive behaviors the text uses the die i c e method nurses often just want to sedate an aggressive patient because it's easier but behavior is always communication die i c e helps us figure out what they're saying d is describe the behavior he's hitting the nurse during a bath i is investigate the cause is he in pain is he constipated is the bath water too cold is he just terrified because he doesn't know who's touching him c is create a plan treat the constipation warm the room explain every step of the bath slowly and e is evaluate did it work usually aggression is just an met physical or emotional need expressed badly also the text consistently proves that music therapy is fantastic for reducing agitation without drugs finally we have to talk about those drugs pharmacology table eighteen point eleven are there any magic pills here short answer no there is no cure the drugs we have the FDA approved ones offer mild symptom control they slow the decline for maybe six to twelve months that's really it let's run through the classes for the students first colon estrous inhibitors the main drugs are done pizol which is arisept ravastignin which is excellent and galant me and the mechanism of action remember we said a settle calling is critically low these drugs inhibit the enzyme that normally eats acetylcholine so whatever little bit the brain is still making hangs around in the synapses longer the target here is mild to moderate all timers the big side effects to watch for our g i issues nausea vomiting diarrhea really stimulates the gut them for the later stages we use mementine brand -name namenda its mechanism is different it's an nmda receptor antagonist it blocks glutamate glutamate is an excitatory chemical in alzheimer's there's too much of it leaking out overexciting the cells until they literally burn out and die mementine blocks that toxicity the target is moderate to severe all timers and you can take them together yes namzeric is the combination pill of done vortiesel and mementine the text has a massive warning a black box morning regarding anti -psychotics we need to highlight this this is absolutely crucial when patients get agitated or paranoid doctors often prescribe anti -psychotics like hold all or resburdle but the fda is issued a black box warning usage of these drugs and elderly patients with dementia significantly increases the risk of death usually from cardiovascular events or infection they should be used only as an absolute last resort when the person is a clear physical danger to themselves or others and the family must be thoroughly informed of the risk they are chemical restraints and they are dangerous is there any good news in the text any hope for the future research is ongoing immunotherapy vaccines to clear the amyloid plaque is being studied deep brain stimulation is being studied but the most empowering data we have right now is the finger study it showed that intense lifestyle changes eating a mediterranean diet rigorous exercise cognitive training like brain games and aggressively managing blood pressure actually prevented cognitive decline in at -risk elderly people we can't change our genes but we can change our lifestyle and that really matters that is a sliver of light in a very dark chapter we have traveled from the acute chaos of delirium to the slow fading twilight of all timers it's heavy heavy stuff it is but i want to leave the listeners with this final thought we talked a lot about plaques and tangles and neurotransmitters today but at the bedside none of that actually matters what matters is that the human being sitting in front of you is frightened and losing their anchor to the world your job as a nurse isn't to fix the amyloid your job is to be the anchor to be the calm voice to hold the hand to preserve their dignity when they can no longer preserve it themselves that is the true deep dive of nursing is not just science it's profound humanity beautifully said we hope this deep dive helps you not just pass your psychiatric nursing exam but helps you become the kind of nurse we would all want caring for our own parents something to think about next time you see a patient struggling to find the right word this has been the last minute lecture team's deep dive on chapter 18 good luck with your studies take care everyone