Cognitive Disorders

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Cognitive Disorders

• Elisa A. Mancuso RNC, MS, FNS
• Professor

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Delirium

• Identified cerebral disease or dysfunction
• Acute fluctuating
• Impaired cognition
• Decision making
• Problem solving
• Interpreting environment
• Learning new information
• Disturbed consciousness
• Disoriented to time place
• Illusions, hallucinations, anxiety, ? sleep
  patterns
• Psychomotor Agitation

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Delirium Etiology

• General Medical Conditions
• UTI URI CHF (Older acutely ill) PN
• Systemic Disturbances
• Fluid/Electrolyte imbalance
• Thiamine deficiency
• Exogenous Substances
• Heavy metals- Lead (Pb) Mercury (Hg)
• ?? Coke Heroin Marijuana ETOH
• Medications
• Benzodiazepenes Sedatives/Hypnotics
• Analgesics Anticonvulsants Diuretics
• Neuroleptics Antihypertensives Digoxin
• Resolve underlying cause condition improves!

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Dementia

• Develops slowly
• 80 Irreversible
• Progressive deterioration
• Multiple Cognitive Deficits
• Impaired short long term memory
• Aphasia ?Language
• Apraxia ? Motor function
• Agnosia Inability to recognize objects
• ? Abstract Thinking
• ? Self-Care

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Senile Dementia

• 6 people gt age 65 or 30 gt age 90
• Syndrome of acquired, persistent intellectual
  impairment
• Etiology
• Cerebral hypoxia Intracranial tumors
• Hydrocephalus MS
• Hypertensive Encephalopathy
• Symptoms
• Short-term memory deficit
• Aphasia
• Confabulation Blocking
• ? Abstract thinking
• Poor judgment impulse control
• Disintegrating personality

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Alzheimers Degenerative Dementia

• 70 of all dementia 4 million people
• Slow insidious onset
• Progressive chronic deterioration
• 8-15 years from onset
• Women 2xgtmen
• Irreversible
• ACh deficiency ? neuron impulse
• ? Aluminum accumulation
• Altered immune system
• ? Ab titers (Protein A-68)
• ? Beta Amyloid
• Neuronal plaques Neurofibrillary tangles
• Cortex atrophy

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Alzheimers

• Predisposing Factors
• Head trauma
• Genetic Chromosome 14, 19 21
• Vascular injury 2 to HTN or cerebral emboli
• Huntingtons Chorea
• Parkinsons Disease
• Picks Disease
• Degeneration of frontal lobe
• Creutzfeldt-Jakob Disease
• Infectious process
• Secondary to HIV

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Alzheimers Phases

• Phase I Forgetfulness (1 year)
• Short term memory loss (Absent minded)
• Lose things forget names of people
• Pt aware tries to compensate
• Anxious fearful regarding losing abilities
• Frustrated

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Alzheimers Phases

• Phase II Confusion (2-12 years)
• Hyperorality
• Tantrums Wandering
• Sundowning
• Afternoon Worsening Agitation Confusion
• Difficulty concentrating yet denies problem
• Lost when driving
• ? Work performance
• Inability to learn new information or recall
  information
• Perservation
• Verbalize same idea repeatedly
• Agnosia
• Failure to identify objects

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Alzheimers Phases

• Phase III- Terminal Dementia (8 mos -2 years)
• Severe significant decline in functioning
• ? Memory of major life events family members
• Regression
• Poor impulse control
• ? Sexual behavior
• Unable to do ADLs independently
• Incontinent
• Delusions, Hallucinations, Anxiety
• Aphasia, Agraphia Apraxia
• Final vegetative state

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Nursing Interventions

• Physical Exam
• R/O any organic cause
• PET, CT, MRI
• v Neurofibrillary tangles atrophy of cortex
• Hx of onset
• Family, friends colleagues
• Assess Mental Status
• Orientation Affect
• Concentration Memory
  Coordination Abstract Thinking
• Judgment Sensory Perception

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Nursing Interventions

• PALMER
• Perception
• Attention Span
• Language
• Memory
• Emotional Control
• Reasoning Judgment

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Nursing Interventions

• 1 Patient Safety!
• ID bracelet
• Notify Police local stores
• Recent photo all contact s
• Physical Environment
• Security system in home
• Childproof
• Consistent uncluttered
• ? Stimulation
• Well lit handrails

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Nursing Interventions

• Psychological Support
• Supportive touch
• Promote interaction
• Group activity
• Reminiscence therapy
• Life review
• Stimulates remote memory
• Promotes ?self-esteem
• Distraction
• Music therapy

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Nursing Interventions

• ADLs
• Allow Pt to make simple choices ? control
• Break down tasks to short, simple steps KISS
• Give verbal visual cues
• Clear expectations
• Allow ample time to perform
• Velcro, elastic, large zippers sneakers
• Exercise
• ROM PT daily walks
• ? activity in day ? wandering _at_ night

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Nursing Interventions

• Nutrition
• Keep mealtimes consistent
• Provide finger foods
• Balance diet with? calorie liguids
• Weigh weekly
• Use bowls spoons Bibs drop cloths
• Elimination
• v I O
• ? Fluids _at_ bedtime
• Toilet _at_ regular intervals q 2h
• Incontinent products

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Medications

• Help delay or prevent worsening of symptoms
• Start low go slow with dosages!
• Cholinesterase Inhibitors
• Donepezil (Aricept)
• Slows the natural breakdown of ACh ? ACh
• Only effective on intact cholinergic neurons
• SE
• Insomnia ? Wandering
• Diarrhea N V
• Rivastigimine (Exelon)
• Transdermal Patch
• SE
• N V Abdominal pain ?Appetite

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Cholinesterase Inhibitors

• Galantamine (Reminyl, Razadyne)
• SE
• N V ?Appetite Dizziness
• Memantine (Nemenda)
• ? Availabilty of ACh
• Target symptoms _at_ mod ? severe stage
• Time limited benefits
• SE
• ?? BP Pain HA
• Vomiting Constipation

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Symptomatic Management

• Anxiolytics
• Short term use to ? anxiety
• BuSpar best ? cognitive psychomotor SEs
• Antipsychotics
• ? Agitation ? Aggression ? Hallucinations
• ? Paranoid thinking
• Zyprexia Seroquel best ? EPS
• Antidepressants
• ? Sleeping ? Thinking ? Memory ? Appetite
• TCA ¼ -1/2 dose
• Bupropion (Wellbutrin) Vanlafaxine (Effexor)
• SSRIs
• No Fluoxetine (Prozac) inhibits liver enzymes
• ? serum levels of other meds
• Paroxetine (Paxil) Citalopram (Celexa)
• Anticonvulsants

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Multidisciplinary Approach

• Speech Therapist
• Restore swallowing
• Delay aphasia
• Physical Therapist
• Use it or lose it
• Retain strength memory
• Improve large fine motor skills
• Occupational Therapist
• Sensory Brain stimulation
• ADL Self-care training program

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Multidisciplinary Approach

• Social Worker
• Individual Group Therapy
• Family Support
• Sandwich generation
• ? Caretaking demands multiple roles
• Coping with feelings of personal loss
• Anticipatory Grieving
• Assistance from all relevant agencies
• Alzheimer's Association
• Community Resources
• Respite care
• Day Care Centers
• Residential Facilities
• Specialized Alzheimers units