Cognitive Disorders

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CHAPTER 17

• Cognitive Disorders

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Etiology

• Delirium
• An underlying systemic illness, including
  infection, and endocrine disorder, trauma, and
  drug/alcohol abuse
• Dementia
• Classified as to the cause or area of brain
  damage
• Amnestic disorders
• Head trauma, hypoxia, encephalitis, thiamine
  deficiency, and substance abuse

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Differentiating Types of Cognitive Disorders

• Delirium
• Acute confusional state characterized by
  disruptions in thinking, perception, memory
• Dementia
• Chronic state characterized by declines in
  multiple cognitive areas, including memory
• Amnestic disorders
• Uncommon cognitive disorder characterized by
  amnesia

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Delirium Clinical Picture

• Disturbances in consciousness
• Change in cognition
• Develops over a short period of time
• Common in hospitalized patients, especially older
  adults
• Always secondary to another physiological
  condition
• Is a transient disorder
• If underlying condition corrected, complete
  recovery should occur

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Delirium Assessment

• Four cardinal features
• Acute onset and fluctuating course
• Inattention
• Disorganized thinking
• Disturbance of consciousness

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Delirium Assessment

• Cognitive and perceptual disturbances
• Illusions
• Hallucinations
• Physical needs
• Mood and physical behaviors
• Attention span
• Reasoning
• Sleep and wake cycle

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Delirium Nursing Diagnoses

• Risk for injury
• Acute confusion
• Deficient fluid volume
• Insomnia, Sleep deprivation
• Impaired verbal communication
• Fear
• Self-care deficit
• Disturbed thought process

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DeliriumOutcomes Identification

• Patient will return to premorbid level of
  functioning.
• Patient will remain safe and free from injury
  while in the hospital.
• Patient will be oriented to time, place, and
  person.
• Patient will be free from falls and injury.

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Delirium Implementation

• Prevent physical harm due to confusion,
  aggression, or fluid and electrolyte imbalance.
• Perform comprehensive nursing assessment to aid
  in identifying cause.
• Assist with proper health management to eradicate
  underlying cause.
• Use supportive measures to relieve distress.

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Interventions for Delirium

• Introduce self and call client by name at each
  contact
• Maintain face-to-face contact
• Use short, concrete phrases
• Keep room well lit
• Keep environmental noise low
• Set limits on behavior
• 11 staffing as needed

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Delirium Evaluation

• Patient will remain safe.
• Patient will be oriented to time, place, and
  person by discharge.
• Underlying cause will be treated and ameliorated.

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Dementia

• Progressive deterioration of cognitive
  functioning and global impairment of intellect
• No change in consciousness
• Difficulty with memory, thinking, and
  comprehension
• Majority of dementias are irreversible

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DementiaPrimary Versus Secondary

• Primary
• Irreversible
• Progressive
• Not secondary to any other disease
• Example Alzheimer's disease
• Secondary
• Result of some other pathological process
• Example AIDS-related dementia

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Alzheimers Disease Etiology

• Biological factors
• Cerebral atrophy
• Neurofibrillary tangles
• Neuritic plaques
• Genetic
• Dementia of Alzheimers type
• Dementia from Huntingtons disease
• Dementia from Picks disease

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Alzheimers Disease Etiology

• Environmental factor
• Dementia from CreutzfeldtJakob disease

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Nursing Process

• Assessment
• Confabulation
• Perseveration
• Cardinal symptoms observed in AD
• Amnesia or memory impairment
• Aphasia
• Apraxia
• Agnosia
• Disturbances in executive functioning

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Nursing Process

• Poor judgment
• Decline in previous abilities

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Stages ofAlzheimer's Disease

• Stage 1 (Mild) forgetfulness
• Stage 2 (Moderate) confusion
• Stage 3 (Moderate to Severe) unable to identify
  familiar objects or people
• Stage 4 (Late) end-stage

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Alzheimers Disease Nursing Diagnoses

• Risk for injury
• Impaired verbal communication
• Impaired environmental interpretation syndrome
• Impaired memory
• Confusion
• Caregiver role strain

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Alzheimer's Disease Outcomes Identification

• Areas to target
• Injury
• Communication
• Agitation level
• Caregiver role strain
• Impaired environmental interpretation chronic
  confusion
• Self-care needs

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Alzheimer's DiseasePlanning

• Geared towards persons immediate needs
• Identify level of functioning
• Assess caregivers needs
• Plan and identify appropriate community resources

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Alzheimer's Disease Implementation

• Maintain optimal nutrition
• Counseling and communication techniques
• Health teaching and health promotion
• Referral to community supports
• Structure the environment to support cognitive
  functions
• Pharmacological interventions

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Pharmacological Interventionsfor Alzheimers
Disease

• Tacrine (Cognex)
• Donepezil (Aricept)
• Rivastigmine (Exelon)
• Galantamine (Razadyne)
• Memantine (Namenda)
• Slows the rate of cognitive decline
• Potent acetylcholinesterase inhibitors

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Common Medications for Cognitive Disorders

• Dementia with Lewy Bodies
• Escitalopram (Lexapro)
• Reduce symptoms of depression when present
• Picks Disease
• Valproic Acid (Depakote)
• Reduce problematic mood swings and agitated
  behavior
• Vascular Dementia with psychosis
• Quetiapine (Seroquel)
• Reduce or eliminate delusions and hallucination

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Amnestic Disorder

• Characterized by short-and long-term memory
  deficits
• Inability to recall previously learned
  information or past events
• Inability to learn new materials
• Cofabulation, apathy, bland affect
• Amnestic disorder NOS not enough supporting
  evidence to link a cause to the amnesia (medical
  or substance)

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Depression

• Depression can be masked by symptoms suggestive
  of dementia
• The term pseudodementia is used to describe the
  reversible cognitive impairments seen in
  depression
• Pseudodementia is characterized by an abrupt
  onset, rapid clinical course, and client
  complaints about cognitive failures

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Caregiver Difficulties

• Wandering behaviors
• Sundowning disorientation
• Activities of Daily Living
• Medication management
• Burnout and fatigue

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Caregiver Resources

• Family meetings
• Alzheimers Disease and Related Disorders
  Association (ADRDA)
• Caregiver support groups
• Identify community resources
• ID bracelet for the client