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
