Neurocognitive Flashcards
Cognition
System of interrelated abilities such as perception, reasoning, judgment, intuition, and memory. Allows one to be aware of oneself in relation to others
Memory
Facet of cognition, retaining and recalling past experiences
Delirium
Acute cognitive impairment with rapid onset caused by a medical condition
Dementia
Chronic cognitive impairment; differentiated by causes not symptoms
Sundowning
the tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night.
Expressive aphasia
cannot find the words to express ideas (Broca’s area)
Receptive Aphasia
cannot interpret what is said (Wernicke’s)
Apraxia
Loss of purposeful movement
Agnosia
Loss of ability to recognize objects
Confabulation
unconscious creation of stories or answers in place of actual memories (maintains self esteem)
Perservation
persistent repetition of a work, phrase, or gesture
Hyperorality
tendency to put things in the mouth to taste and chew
Causes of Delirium
- Medications
- Infections
- Fluid and electrolyte imbalances
- Hypoxia/ischemia
- Brain alterations
Brain alterations
- Reduction in cerebral functioning or brain metabolism
- increased plasma cortisol level
- neurotransmitter imbalance
- Damage to enzyme systems, blood-brain barrier, or cell membranes
Clinical Picture of Delirium
- Disturbance in attention and awareness
- Acute onset (hours to a few days); change from baseline; fluctuates with periods of lucidity over course of a 24-hour day
- There is a direct physiological cause
Patients with delirium may experience..
- Memory deficit
- Disorientation
- Language changes
- Visuospatial ability
- Delusions and hallucinations (usually visual)
- Disturbances in sleep-wake pattern
Four cardinal features
- Acute onset and fluctuating course
- Reduced ability to direct, focus, shift, and sustain attention
- Disorganized thinking
- Disturbance of consciousness
Outcomes Criteria for Delirium
- Patient will remain safe and free from injury
- During periods of clarity, patient will be oriented to time, place, and person
- Patient will remain free from falls & injury while confused, with nursing safety measures
- Patient and family verbalize understanding of the cause, course of illness, and treatment regimen
Planning for Delirium
- Ensure necessary aids and supportive home team
- Visual cues in the environment for orientation
- Continuity of care providers
Interventions for Delirium: Orientation
- Encouraged to express fears and discomfort
- Comfort measures to instill trust
- Frequent verbal orientation
- Frequent brief interaction
- Attempt consistency in nursing staff
- Allow television during day with daily news.
- Play non-verbal music
- Approach patient slowly and from the front and address patient by name
Interventions for Delirium: Environment
- Adequate lighting
- Easy-to-read calendars and clocks
- Reasonable noise level: decrease stimulation especially at night.
- Sleep hygiene; minimize disruptions; lower lighting
- Provide safety- physical (lower bed and careful supervision)
- Provide symptomatic & supportive care (Hydration, nutrition, comfort and pain control, reassurance and companionship to instill trust)
Interventions for Delirium: Pharmacological
Medicate with very small doses of antipsychotics
Or benzodiazepines: lorazepam (watch for opposite action of agitation – if hepatic dysfunction use these instead of Antipsychotics)
Sleep aids: mirtazapine (Remeron)
Pain control: assess objectively; consider intermittent narcotics
Identify possible drug-drug interactions: 10 meds = 100% chance of a drug-drug interaction
Must treat the underlying cause
Nursing Care Summary
- Provide safety- physical (lower bed and careful supervision)
- Assess medication management (eliminate / choose carefully / slow and low dosing)
- Provide symptomatic & supportive care (Hydration, nutrition, comfort and pain control, reassurance and companionship to instill trust)
- Meet the patient’s basic human needs
- Build trust in the patient-establish therapeutic rapport.
Communication
- Use short, simple sentences.
- Speak slowly and clearly, pitching voice low to increase likelihood of being heard; do not act rushed, do not shout.
- Identify self by name at each contact; call client by their preferred name.
- Repeat questions if needed, allowing adequate time for response.
- Point to objects or demonstrate desired actions.
- Tell clients what you want done - not what not to do.
- Listen to what the client says and observe behaviors to identify the message, emotion, or need that is being communicated.
- Educate the client (when not confused) and family.
- Encourage to express fears and discomfort
- Frequent, brief, verbal orientation
Dementia
Degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death
Neurocognitive Disorders
- Progressive deterioration of cognitive functioning and global impairment of intellect
- No change in consciousness
- The condition is acquired; not developmental
- Difficulty with memory, problem solving, and complex attention
- Affects orientation, attention, memory, vocabulary, calculation ability, and abstract thinking
Mild Neurocogntive Disorders
Does not interfere with ADLs; does not necessarily progress
Major Neurocognitive Disorders
Interferes with daily functioning and independence
Major Neurocognitive Disorders
- Alzheimer Disease
- Frontotemporal Dementia
- Dementia with Lewy bodies
- Vascular Dementia
- Traumatic Brain injury
- Substance-induced dementia
- HIV infection
- Prion disease
- Parkinson’s Disease
- Huntington’s Disease
MMSE
can’t name penic, watch, shoe
Risk Factors of AD
- Age and family history
- Cardiovascular disease
- Social engagement and diet
- Head injury and traumatic brain injury
- HTN and dyslipidemia
Biological Factors AD
- Neuronal degeneration
- Genetics
Etiology of AD
- Tau proteins and beta-amyloid plaques create neurofibrillary tangles
- Amyloid plaques
- Neurofibrillary tangles
- Oxidative stress and free radicals
- Inflammation
- Brain atrophy
Amyloid plaques
Sticky clumps between nerve cells
Neurofibrillary tangles
abnormal collections of protein threads inside nerve cells
Brain Atrophy
- Cerebral cortex shriveling up, damaging areas involved in thinking, planning, and remebering.
- The hippocampus, an area of the cortex that is essential for memory, experiences serve shrinking.
- Ventricles in the brain grow larger
Acetylcholine in AD
- Involved with learning, memory, and mood. As AD progresses the brain produces less acetylcholine.
- Cholinesterase inhibitors keep the acetylcholinesterase enzyme from breaking down acetylcholine.
Glutamate AD
- Involved with cell signaling, learning, and memory. In AD there is excess glutamate.
- NMDA antagonists helps reduce excess calcium by blocker some NMDA receptors.
Stage 1 AD: No Impairment
- There are no symptoms of memory impairment.
- There is no reason to suspect Alzheimer’s disease
Stage 2: Very Mild Cognitive Decline
There are some minor memory problems noticed, but the person usually does fairly well on memory tests; therefore normal age-related memory loss is concluded.
Stage 3: Mild Cognitive Decline
Memory problems occur, such as finding the correct word in a sentence and remembering people’s names, and the person may forget or lose needed items.
Stage 4: Moderate Cognitive Decline
- The person may have difficulty with simple math, show poor short-term memory, forget some details about his or her life, and by unable to keep up with their bills.
- Symptoms of AD are clearly present.
Stage 5: Moderately Severe Cognitive Decline
- The person may begin to need assistance with activities of daily life.
- Significant confusion may be evident.
- Although still somewhat functional, the person may need assistance recalling his or her phone number and dressing but not with toileting or bathing.
- The person typically still knows those close to them (e.g., family members) and has most of long-term memory intact.
Stage 6: Severe Cognitive Decline
- The person needs continuous supervision and frequently requires care by professionals.
- The person has undergone significant personality changes and is usually unaware of surroundings and may not recognize faces of most people except close friends and family.
- There may be some resistant or aggressive behavior exhibited, and the person needs greater assistance with activities of daily living (i.e., toileting and bathing).
- The person may have lost bowel and bladder control, and there is the potential for unsafe wandering.
- Stages 7: Very Severe Decline
- Stage seven is the final stage of Alzheimer’s disease, in which the patient is nearing death.
- The patient loses the ability to respond to the environment or to communicate.
- The patient may still be able to utter words and phrases but has no insight into his or her condition and needs assistance with all activities of daily living.
- In the final stages of the illness, the patient may lose the ability to swallow.
Mild AD
Forgetfulness, misplace articles, decreased recall, social withdrawal, frustrated with self, changes may not be apparent to others
Moderate
decreased ability for self-care; way-finding; disoriented to time and place; wandering, pacing, possible hallucinations or delusions begin, decreased visual perception leading to accidents; needs supervision; emotional lability-big swings; symptoms noticeable
Severe
cannot care for self; loss use of language; minimal long-term memory; constant complete care
Biologic Domain in Dementia
Past and present health status (compare to norms)
Physical examination and review of systems (Dementia)
- Vital signs
- neurologic status
- nutritional status
- bladder and bowel function
- hygiene
- skin integrity
- rest and activity
- sleep patterns
- fluid and electrolyte balance
Physical Functions of Dementia
- Self-care
- Sleep–wake disturbances
- Activity and exercise
- Nutrition
- Pain
Assess for these in Dementia pt
- Confabulation
- Perseveration
- Agraphia
- Hyperorality
- Aphasia
- apraxia
- agnosia
- Sundowning / sundown syndrome
Psychological (Dementia)
- Suspiciousness, delusions, and illusions
- Hallucinations
- Mood changes
- Anxiety
- Catastrophic reactions
Defense Mechanisms in Dementia
- Denial
- Confabulation
- Perseveration
- Avoidance of questions
Behavioral responses in Dementia
- Apathy and withdrawal
- Restlessness, agitation, and aggression
- Aberrant motor behavior
- Disinhibition
- Hypersexuality
- Signs of stress, anxiety
Social Domain in Dementia
- Social system
- Spiritual assessment
- Legal status- i.e., guardianship
- Quality of life
- Primary caregiver support essential to well-being of person with dementia.
Diagnostic Tests
- Computed tomography scan (CT)
- Positron emission tomography (PET)
- Mental status questionnaires
- Mini-Mental State Examination
- Complete physical and neurological exam
- Complete medical and psychiatric history
- Review of recent symptoms, meds, and nutrition
Nursing Diagnoses in Dementia
- Impaired sleep
- Risk for injury (& wandering)
- Self-care deficit
- Anxiety
- Confusion
- Impaired verbal communication
- Hopelessness
- Caregiver stress
- Anticipatory grief
Dementia: Priority Care Issues
- Priorities will change throughout the course of the disorder
- Initially, delay cognitive decline
- Moderate level: protect patient from hurting self
- Late stages: physical needs become the focus of care
INTERVENTIONS: CONFUSION/AGITATION
- Speak clearly, slowly, directly
- Don’t approach from behind
- Face patient
- Use of para-verbal and nonverbal communication techniques
- Walk or walk/talk with patient if h/she is restless
- Picture albums of pets, wildlife, scenery
- Music- that the person likes
- Patience, patience, patience
Self-care
- Maintaining independence as much as possible
- Oral hygiene
Nutritional
- Monitoring patient’s weight, oral intake, and hydration
- Well-balanced meals
- Observation for swallowing difficulties
Nursing Interventions
- Supporting bowel and bladder function
- Sleep interventions
- Activity and exercise: balance activity with sleep
- Pain & comfort management: assess carefully; do not rely on verbalizing pain
- Relaxation
AD Medications: Acetylcholinesterase inhibitors (AChEI)
- Donepezil
- Rivastigmine p.o. and transdermal patch
- Galantamine
- Indicated for mild to moderate AD
- Used to delay not decrease cognitive decline (used to stabilize memory, language and orientation).
- Most common side effects: nausea, vomiting
- Peaks in 3 months but continues to delay decline
Memantine (NMDA antagonist)
- modulation of N-methyl-D-aspartate (NMDA) receptor activity
- restore the function of damaged nerve cells and reduce abnormal excitatory signals of the NT glutamate
- Mild side effects of dizziness, confusion, headaches and constipation
Medications for Behavioral Symptoms
Antipsychotics- may increase risk of mortality; use with extreme caution
Antidepressants
Antianxiety
Anticonvulsants
