Chapter 24 Cognitive Disorders Flashcards
Cognition
The brain’s ability to process, retain, and use information
Cognitive Abilities
Essential for many important tasks, including making decisions, solving problems, interpreting the environment, and learning new information
Abilities: Reasoning, judgment, perception, attention, comprehension, and memory.
Cognitive Disorder
A disruption or impairment in these higher level functions of the brain
Neurocognitive Disorders (NCDs)
DSM5 Categorizes NCD to include:
- Delirium
- Major NCD (Dementia)
- Mild NCD
- And subtypes via etiology
Signs & symptoms often mimic other mental illnesses & physical illnesses
Difficult to obtain direct evidence for a definitive diagnosis w/out time & tests needed to be run
Delirium
A syndrome that involves a disturbance of consciousness accompanied by a change of cognition
Common Causes & Risk Factors for Delirium
Most frequent in older adults
Medications (e.g., drug intoxication)
Substance use or withdrawal
Infections (e.g., sepsis, UTI, pneumonia)
Fluid and electrolyte imbalances; nutritional deficiencies
Hypoxia or ischemia
Metabolic disturbances
Brain tumor or head injury
Surgery
Change in environment (e.g., Hospitalization/ICU)
Restraint use
Terminally ill
Drugs Causing Delirium
Anesthesia
Anticonvulsants
Anticholinergics
Antidepressants
Antihistamines
Antihypertensives
Antineoplastics
Antipsychotics
Aspirin
Barbiturates
Benzodiazepines
Cardiac glycosides
Cimetidine (Tagamet)
Hypoglycemic agents
Insulin
Narcotics
Propranolol (Inderal)
Reserpine
Steroids
Thiazide diuretics
Children are more susceptible to delirium , especially related to…
…a febrile illness or certain meds (anticholinergics)
(T/F) True or False: Delirium almost always results from an identifiable case
True
Nursing Assessment: General Appearance & Motor Behavior
They may be restless and hyperactive, frequently picking at bedclothes or making sudden, uncoordinated attempts to get out of bed.
- Conversely, clients may have slowed motor behavior, appearing sluggish and lethargic with little movement.
Speech may also be affected, becoming less coherent and more difficult to understand as delirium worsens.
Clients may perseverate on a single topic or detail, may be rambling and difficult to follow, or may have pressured speech that is rapid, forced, and usually louder than normal
At times, clients may call out or scream, especially at night
Nursing Assessment: Mood & Affect
Often have rapid and unpredictable mood shifts
- A wide range of emotional responses is possible, such as anxiety, fear, irritability, anger, euphoria, and apathy
These mood shifts and emotions usually have nothing to do with the client’s environment.
When clients are particularly fearful and feel threatened, they may become combative to defend themselves from perceived harm
Nursing Assessment: Thought Process & Content
Difficult for the nurse to assess these changes accurately and thoroughly
Marked inability to sustain attention makes it difficult to assess thought process and content
Thought content in delirium is often unrelated to the situation, or speech is illogical and difficult to understand.
Ex) The nurse may ask how clients are feeling, and they will mumble about the weather
Thought processes are often disorganized and make no sense.
- Thoughts may also be fragmented (disjointed and incomplete)
Clients may exhibit delusions, believing that their altered sensory perceptions are real.
Nursing Assessment: Sensorium and Intellectual Processes
Primary and often initial sign of delirium is an altered level of consciousness that is seldom stable and usually fluctuates throughout the day
Clients are usually oriented to people but frequently disoriented to time and place
- Decreased awareness of the environment or situation and may instead focus on irrelevant stimuli such as the color of the bedspread or the room.
-Noises, people, or sensory misperceptions easily distract them.
Clients cannot focus, sustain, or shift attention effectively, and there is impaired recent and immediate memory.
- This means the nurse may have to ask questions or provide directions repeatedly. Even then, clients may be unable to do what is requested.
Clients frequently experience misinterpretations, illusions, and hallucinations.
- Both misperceptions and illusions are based on some actual stimuli in the environment
Ex) Clients may hear a door slam and interpret it as a gunshot or see the nurse reach for an IV bag and believe the nurse is about to strike them.
Hallucinations are most often visual; clients “see” things for which there is no stimulus in reality.
When more lucid, some clients are aware that they are experiencing sensory misperceptions.
- Others, however, actually believe their misinterpretations are correct and cannot be convinced otherwise
Nursing Assessment: Judgement and Insight
Judgment is impaired
Clients often cannot perceive potentially harmful situations or act in their own best interests
Insight depends on the severity of the delirium
- Clients with mild delirium may recognize that they are confused, are receiving treatment, and will likely improve.
- Those with severe delirium may have no insight into the situation
Nursing Assessment: Roles and Relationships
Unlikely to fulfill their roles during the course of delirium
Most regain their previous level of functioning, however, and have no long-standing problems with roles or relationships
Nursing Assessments: Self-Concept
Clients are often frightened or feel threatened
Those with some awareness of the situation may feel helpless or powerless to do anything to change it
If delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt, shame, and humiliation, or think, “I’m a bad person; I did this to myself.”
- This would indicate possible long-term problems with self-concept
Nursing Assessment: Physiological and Self-Care Considerations
Most often experience disturbed sleep–wake cycles that may include difficulty falling asleep, daytime sleepiness, nighttime agitation, or even a complete reversal of the usual daytime waking/nighttime sleeping pattern
At times, clients also ignore or fail to perceive internal body cues such as hunger, thirst, or the urge to urinate or defecate
Treatment Goal for Patients w/ Delirium
Goal: Minimize risk factors in order to prevent delirium AND identify underlying cause!
Delirium is almost always a transient condition that clears with successful treatment of the underlying cause.
- Some causes such as head injury or encephalitis may leave clients w/ cognitive, behavioral, or emotional impairments even after the underlying cause resolves
(T/F) True or False: People who have had delirium are at higher risk for future episodes
True
(T/F) True or False: Delirium is usually reversible if it is treated and diagnosed promptly
True, treat delirium as a medical emergency
Psychopharmacology & Delirium
Clients with quiet, hypoactive delirium need no specific pharmacologic treatment aside from that indicated for the causative condition.
Many clients with delirium, however, show persistent or intermittent psychomotor agitation, psychosis, and/or insomnia that can interfere with effective treatment or pose a risk to safety.
Sedation to prevent inadvertent self-injury may be indicated.
- An antipsychotic medication, such as haloperidol (Haldol), may be used in doses of 0.5 to 1 mg to decrease agitation and psychotic symptoms, as well as to facilitate sleep.
- Haloperidol is useful in a variety of situations because it can be administered orally, (IM), or (IV)
Historically, short- or intermediate-acting benzodiazepines, such as lorazepam (Ativan), have been used, but benzodiazepines may worsen delirium, especially in older adults.
- Their use should be reserved for treatment of sedative–hypnotic withdrawal.
Clients with impaired liver or kidney function could have difficulty metabolizing or excreting sedatives.
The exception is delirium induced by alcohol withdrawal, which is usually treated with benzodiazepines
General Interventions for Delirium
Perform thorough initial assessment w/ frequent reassessments
Eliminate or correct underlying cause
Provide a safe environment
Coordinate interdisciplinary treatment
Provide symptomatic and supportive measures
Nutrition (food & fluid intake)
Do things to promote optimal vision and hearing
Biological Interventions for Delirium
Stop suspected medications
Monitor changes in vital signs, behavior, and mental status
Maintain adequate hydration and fluid and electrolyte balance
Promote adequate sleep and nutrition; encourage daily routines
Prevent aspiration and skin breakdown
Keep eyeglasses and hearing aids readily available
Administer medications as prescribed (e.g., antipsychotics or anxiolytics) and monitor for side effects
Psychological Interventions for Delirium
Provide frequent interaction and support
Gently present reality as needed
Encourage expression of fears and discomforts
Provide a comfortable, orienting environment
Ex) Adequate lighting, comfortable noise level, easy-to-read calendars and clocks, introduce oneself
Reduce stimuli
For confusion, limit choices, be accepting, provide step-by-step directions
Restraints as last resort
Sociological Interventions for Delirium
Utilize de-escalation techniques as needed
Involve family if possible
Patient and Family Education for Delirium
Monitor chronic health conditions carefully
Visit physician regularly.
Tell all physicians and health care providers what medications are taken, including OTC medications, dietary supplements, and herbal preparations.
Check with physician before taking any nonprescription medication.
Avoid alcohol and recreational drugs.
Maintain a nutritious diet.
Get adequate sleep.
Use safety precautions when working with paint solvents, insecticides, and similar products
Dementia
Refers to a disease process marked by progressive cognitive impairment w/ no change in the level of consciousness
It involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive disturbances may be seen:
- Aphasia
- Apraxia
- Agnosia
- Executive functioning
Aphasia
Deterioration of language function
Apraxia
Impaired ability to execute motor functions despite intact motor abilities
Agnosia
Inability to recognize or name objects despite intact sensory abilities
Executive Functioning
The ability to think abstractly and to plan, initiate, sequence, monitor, and stop complex behavior
DSM-5 Mild NCD
Refers to a mild cognitive decline & a modest impairment of performance that doesn’t prevent independent living but that may require some accommodation or assistance
DSM-5 Severe NCD
Refers to a significant cognitive decline & a substantial impairment in performance that interferes with activities of daily independent living
Key Differences between Delirium & Dementia
Onset:
- Delirium: Rapid
- Dementia: Gradual & Insidious
Duration:
- Delirium: Brief (hrs –days)
- Dementia: Progressive deterioration
LOC:
- Delirium: Impaired, fluctuates
- Dementia: Not affected
Memory:
- Delirium: Short-term memory impaired
- Dementia: Short- and then long-term memory impaired, eventually destroyed
Speech:
- Delirium: May be slurred, rambling, pressured, irrelevant
- Dementia: Normal in early stage, progressive aphasia in later stage
Thought Process:
- Delirium: Temporarily disorganized
- Dementia: Impaired thinking, eventual loss of thinking abilities
Perception:
- Delirium: Visual or tactile hallucinations, delusions
- Dementia:Often absent, but can have paranoia, hallucinations, illusions
Mood:
- Delirium: Anxious, fearful if hallucinating; weeping, irritable
- Dementia: Depressed and anxious in early stage, labile mood, restless pacing, angry outbursts in later stages
If both dementia & delirium coexist…
…symptoms of dementia will remain after the delirium has passed
What is the prominent early sign of dementia?
Memory impairment
Initially, recent memory is impaired
Ex) The patient may forget where certain items where placed or food is still on the stove
Later Stages: Dementia affects remote memory
Ex) Clients forget the names of adult children, their lifelong occupations, and even their own names.
Symptom Progression in Dementia
Speech: Usually begins with the inability to name familiar objects or people (Aphasia)
- Then progresses to speech that becomes vague or empty with excessive use of terms such as it or thing.
- Clients may exhibit echolalia or palilalia
Apraxia: May cause clients to lose the ability to perform routine ADLs
Agnosia: Frustrating for clients; they may look at a table and chair but are unable to name them.
Disturbances in executive functioning are evident as clients lose the ability to learn new material, solve problems, or carry out ADLs such as meal planning or budgeting
Mild Phase of Dementia
Forgetfulness is the hallmark of beginning, mild dementia.
- It exceeds the normal, occasional forgetfulness experienced as part of the aging process
The person has difficulty finding words, frequently loses objects, and begins to experience anxiety about these losses
Occupational and social settings are less enjoyable, and the person may avoid them
Most people remain in the community during this stage
Moderate Phase of Dementia
Confusion is apparent, along with progressive memory loss.
The person can no longer perform complex tasks but remains oriented to person and place.
- They still recognize familiar people.
Toward the end of this stage, the person loses the ability to live independently and requires assistance because of disorientation to time and loss of information, such as address and telephone number.
The person may remain in the community if adequate caregiver support is available, but some people move to supervised living situations
Severe Phase of Dementia
Personality and emotional changes occur
The person may be delusional, wander at night, forget the names of their spouse and children, and require assistance with ADLs
Most people live in nursing facilities when they reach this stage, unless extraordinary community support is available
Risk Factors for Dementia
Advanced age
Prior head trauma
Lifestyle factors (e.g., sedentary)
Genetics (e.g., family history of Alzheimer’s dementia)
Metabolic syndrome or diabetes
Substance use or medication induced
Infections (e.g., HIV)
What is the #1 risk factor for dementia?
Advanced age
Alzheimer’s Disease
A progressive brain disorder that has a gradual onset but causes an:
- Increasing decline in functioning
- Including loss of speech, loss of motor function
- Profound personality and behavioral changes such as paranoia, delusions, hallucinations, inattention to hygiene, and belligerence.
It is evidenced by atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth ventricles of the brain
Risk for Alzheimer’s disease increases with age, and average duration from onset of symptoms to death is 8 to 10 years.
Lewy Body Dementia
A disorder that involves progressive cognitive impairment & extensive neuropsychiatric symptoms as well as motor symptoms
Delusions and visual hallucinations are common
Functional impairments may initially be more pronounced than cognitive deficits.
Several risk genes have been identified, and it can occur in families, although that is less common than no family history
Vascular Dementia
Characterized by a marked disruption in cerebral blood flow with destruction of brain cells
-Blockage of blood vessels leads to brain damage and cognitive impairment
Reduces life expectancy to a greater degree than AD
Can occur suddenly
Frontotemporal Lobar Degeneration
AKA “Pick’s Disease”
A degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of Alzheimer’s disease.
Early signs include personality changes, loss of social skills and inhibitions, emotional blunting, and language abnormalities.
Onset is most commonly 50 to 60 years of age; death occurs in 2 to 5 years.
There is a strong genetic component, and it tends to run in families
Prion Disease
Caused by a prion (a type of protein) that can trigger normal proteins in the brain to fold abnormally.
They are rare, and only 300 cases per year occur in the United States.
Creutzfeldt–Jakob disease is the most common prion disease affecting humans
- It is a CNS disorder that typically develops in adults aged 40 to 60 years.
- It involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses rapidly (a few months).
The cause of the encephalopathy is an infectious particle resistant to boiling, some disinfectants (e.g., formalin, alcohol), and ultraviolet radiation
Parkinson’s Disease
A slowly progressive neurologic condition characterized by tremor, rigidity, bradykinesia, and postural instability.
- It results from loss of neurons of the basal ganglia.
Dementia has been reported in approximately 25% (mild NCD) to as many as 75% (major NCD) of people with Parkinson’s disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning
Huntington’s Disease
An inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of the brain ventricles.
Initially, there are choreiform movements that are continuous during waking hours and involve facial contortions, twisting, turning, and tongue movements.
Personality changes are the initial psychosocial manifestations, followed by memory loss, decreased intellectual functioning, and other signs of dementia.
The disease begins in the late 30s or early 40s and may last 10 to 20 years or more before death
What is the % of patients with Alzheimer’s fall under the dementia category?
50-75%
What is the % of patients with Vascular dementia fall under the dementia category?
20-30%
What is the % of patients with Lewy body disease fall under the dementia category
10-25%
What is the % of patients with Frontotemporal lobar degenration fall under the dementia category?
10-15%
