Cognitive Cognitive DisordersDisorders

Elisa A. Mancuso RNC, MS, FNSElisa A. Mancuso RNC, MS, FNS

ProfessorProfessor

DeliriumDelirium Identified cerebral disease or dysfunctionIdentified cerebral disease or dysfunction

– Acute & fluctuatingAcute & fluctuating Impaired cognitionImpaired cognition

– Decision makingDecision making– Problem solvingProblem solving– Interpreting environmentInterpreting environment– Learning new information Learning new information

Disturbed consciousnessDisturbed consciousness– Disoriented to time & placeDisoriented to time & place– Illusions, hallucinations, anxiety, & Illusions, hallucinations, anxiety, & ▲ ▲ sleep sleep

patternspatterns Psychomotor AgitationPsychomotor Agitation

Delirium EtiologyDelirium Etiology General Medical ConditionsGeneral Medical Conditions

UTIUTI URIURI CHF (Older acutely ill) PNCHF (Older acutely ill) PN Systemic DisturbancesSystemic Disturbances

Fluid/Electrolyte imbalanceFluid/Electrolyte imbalance Thiamine deficiencyThiamine deficiency

Exogenous SubstancesExogenous Substances Heavy metals- Lead (Pb) Mercury (Hg) Heavy metals- Lead (Pb) Mercury (Hg) ↑↑ ↑↑ Coke Coke Heroin Heroin Marijuana Marijuana ETOH ETOH

MedicationsMedications BenzodiazepenesBenzodiazepenes Sedatives/HypnoticsSedatives/Hypnotics AnalgesicsAnalgesics AnticonvulsantsAnticonvulsants DiureticsDiuretics NeurolepticsNeuroleptics AntihypertensivesAntihypertensives DigoxinDigoxin

Resolve underlying cause & condition improves!Resolve underlying cause & condition improves!

Dementia Dementia Develops slowly 80% IrreversibleProgressive deterioration

Multiple Cognitive DeficitsImpaired short & long term memoryAphasia: ↓Language

Apraxia: ↓ Motor function

Agnosia: Inability to recognize objects

↓ Abstract Thinking

↓ Self-Care

Senile DementiaSenile Dementia

6% people > age 65 6% people > age 65 oror 30% > age 9030% > age 90Syndrome of acquired, persistent intellectual impairmentSyndrome of acquired, persistent intellectual impairment

Etiology Cerebral hypoxiaCerebral hypoxia Intracranial tumors Intracranial tumors HydrocephalusHydrocephalus MS MS Hypertensive EncephalopathyHypertensive Encephalopathy

Symptoms Short-term memory deficitShort-term memory deficit AphasiaAphasia ConfabulationConfabulation BlockingBlocking ↓ ↓ Abstract thinking Abstract thinking Poor judgment & impulse controlPoor judgment & impulse control Disintegrating personalityDisintegrating personality

Alzheimer’s Degenerative DementiaAlzheimer’s Degenerative Dementia

70% of all dementia = 4 million people70% of all dementia = 4 million peopleSlow & insidious onsetSlow & insidious onsetProgressive & chronic deteriorationProgressive & chronic deterioration

– 8-15 years from onset8-15 years from onset Women 2x>menWomen 2x>men IrreversibleIrreversible

ACh deficiency =ACh deficiency =↓ neuron impulse↓ neuron impulse ↑ ↑ Aluminum accumulationAluminum accumulation Altered immune system Altered immune system

– ↑ ↑ Ab titers (Protein A-68)Ab titers (Protein A-68) ↑ ↑ Beta AmyloidBeta Amyloid

– Neuronal plaques Neurofibrillary tanglesNeuronal plaques Neurofibrillary tangles– Cortex atrophyCortex atrophy

Alzheimer’sAlzheimer’s

Predisposing FactorsPredisposing Factors Head traumaHead trauma Genetic: Chromosome # 14, 19 & 21Genetic: Chromosome # 14, 19 & 21 Vascular injury 2 to HTN or cerebral emboliVascular injury 2 to HTN or cerebral emboli Huntington’s ChoreaHuntington’s Chorea Parkinsons DiseaseParkinsons Disease Pick’s DiseasePick’s Disease

– Degeneration of frontal lobeDegeneration of frontal lobe

Creutzfeldt-Jakob DiseaseCreutzfeldt-Jakob Disease– Infectious processInfectious process

Secondary to HIVSecondary to HIV

Alzheimer’s PhasesAlzheimer’s Phases

Phase I : Forgetfulness (1 year)Phase I : Forgetfulness (1 year)

– Short term memory loss (Absent minded)Short term memory loss (Absent minded)

– Lose things & forget names of peopleLose things & forget names of people

– Pt aware & tries to compensatePt aware & tries to compensate

– Anxious & fearful regarding losing abilitiesAnxious & fearful regarding losing abilities

– FrustratedFrustrated

Alzheimer’s PhasesAlzheimer’s Phases

Phase II : Confusion (2-12 years)Phase II : Confusion (2-12 years)– HyperoralityHyperorality– Tantrums & WanderingTantrums & Wandering– SundowningSundowning

Afternoon Worsening: Agitation & ConfusionAfternoon Worsening: Agitation & Confusion – Difficulty concentrating Difficulty concentrating yet denies problemyet denies problem

Lost when drivingLost when driving ↓ ↓ Work performanceWork performance Inability to learn new information or recall informationInability to learn new information or recall information

– PerservationPerservation Verbalize same idea repeatedlyVerbalize same idea repeatedly

– AgnosiaAgnosia Failure to identify objectsFailure to identify objects

Alzheimer’s PhasesAlzheimer’s Phases Phase III- Terminal Dementia (8 mos -2 years)Phase III- Terminal Dementia (8 mos -2 years)

– Severe & significant decline in functioningSevere & significant decline in functioning– ↓ ↓ Memory of major life events & family membersMemory of major life events & family members– RegressionRegression– Poor impulse controlPoor impulse control

↑ ↑ Sexual behaviorSexual behavior– Unable to do ADLs independentlyUnable to do ADLs independently

IncontinentIncontinent– Delusions, Hallucinations, AnxietyDelusions, Hallucinations, Anxiety– Aphasia, Agraphia & ApraxiaAphasia, Agraphia & Apraxia– Final vegetative stateFinal vegetative state

Nursing InterventionsNursing Interventions

Physical ExamPhysical Exam– R/O any organic causeR/O any organic cause

PET, CT, MRIPET, CT, MRI √ √ Neurofibrillary tangles & atrophy of cortexNeurofibrillary tangles & atrophy of cortex

Hx of onsetHx of onset Family, friends & colleaguesFamily, friends & colleagues

Assess Mental StatusAssess Mental StatusOrientationOrientation Affect Affect

Concentration Memory Coordination Concentration Memory Coordination Abstract Thinking Abstract Thinking

JudgmentJudgment Sensory Perception Sensory Perception

Nursing InterventionsNursing Interventions

PALMERPALMER– PPerceptionerception– AAttention Spanttention Span– LLanguageanguage– MMemoryemory– EEmotional Controlmotional Control– RReasoning & Judgmenteasoning & Judgment

Nursing InterventionsNursing Interventions

# 1 Patient Safety!# 1 Patient Safety!– ID braceletID bracelet– Notify Police & local storesNotify Police & local stores– Recent photo & all contact #sRecent photo & all contact #s– Physical EnvironmentPhysical Environment

Security system in homeSecurity system in home ChildproofChildproof Consistent & unclutteredConsistent & uncluttered ↓ ↓ StimulationStimulation Well lit & handrailsWell lit & handrails

Nursing InterventionsNursing Interventions Psychological SupportPsychological Support

– Supportive touchSupportive touch– Promote interactionPromote interaction

Group activityGroup activity

– Reminiscence therapyReminiscence therapy Life reviewLife review Stimulates remote memoryStimulates remote memory Promotes Promotes ↑self-esteem↑self-esteem

– DistractionDistraction Music therapyMusic therapy

Nursing InterventionsNursing Interventions ADLsADLs

– Allow Pt to make simple choices = Allow Pt to make simple choices = ↑ control↑ control– Break down tasks to short, simple steps = KISSBreak down tasks to short, simple steps = KISS– Give verbal & visual cuesGive verbal & visual cues– Clear expectationsClear expectations– Allow ample time to performAllow ample time to perform

Velcro, elastic, large zippers & sneakersVelcro, elastic, large zippers & sneakers

ExerciseExercise– ROM PT & daily walksROM PT & daily walks– ↑ ↑ activity in day ↓ wandering @ nightactivity in day ↓ wandering @ night

Nursing InterventionsNursing Interventions NutritionNutrition

– Keep mealtimes consistentKeep mealtimes consistent– Provide finger foodsProvide finger foods– Balance diet withBalance diet with↑ calorie liguids↑ calorie liguids– Weigh weeklyWeigh weekly– Use bowls & spoonsUse bowls & spoons Bibs & drop clothsBibs & drop cloths

EliminationElimination– √ √ I & OI & O– ↓ ↓ Fluids @ bedtimeFluids @ bedtime– Toilet @ regular intervals q 2hToilet @ regular intervals q 2h– Incontinent productsIncontinent products

MedicationsMedicationsHelp delay or prevent worsening of symptoms

Start low & go slow with dosages!

Cholinesterase InhibitorsCholinesterase Inhibitors Donepezil (Aricept)Donepezil (Aricept)

– Slows the natural breakdown of ACh = Slows the natural breakdown of ACh = ↑ ACh↑ ACh– Only effective on intact cholinergic neuronsOnly effective on intact cholinergic neurons– SESE

Insomnia = Insomnia = ↑ Wandering↑ Wandering Diarrhea Diarrhea N & VN & V

Rivastigimine (Exelon)Rivastigimine (Exelon)– Transdermal PatchTransdermal Patch– SESE

N & V N & V Abdominal painAbdominal pain ↓↓AppetiteAppetite

Cholinesterase InhibitorsCholinesterase Inhibitors

Galantamine (Reminyl, Razadyne)Galantamine (Reminyl, Razadyne)– SE

N & V ↓Appetite Dizziness

Memantine (Nemenda)Memantine (Nemenda)– ↑ ↑ Availabilty of AChAvailabilty of ACh– Target symptoms @ mod Target symptoms @ mod →→ severe stage severe stage– Time limited benefitsTime limited benefits– SESE

↑↑ ↑↑ BPBP PainPain HAHA VomitingVomiting ConstipationConstipation

Symptomatic ManagementSymptomatic Management AnxiolyticsAnxiolytics

Short term use to Short term use to ↓ anxiety ↓ anxiety BuSpar BuSpar best = best = ↓ ↓ cognitive & psychomotor SEscognitive & psychomotor SEs

AntipsychoticsAntipsychotics ↓ ↓ AgitationAgitation ↓ Aggression ↓ Aggression ↓ Hallucinations ↓ Hallucinations ↓ ↓ Paranoid thinkingParanoid thinking Zyprexia & SeroquelZyprexia & Seroquel best = ↓ EPS best = ↓ EPS

AntidepressantsAntidepressants ↑ ↑ Sleeping ↑ Thinking ↑ Memory ↑ AppetiteSleeping ↑ Thinking ↑ Memory ↑ Appetite TCATCA ¼ -1/2 dose ¼ -1/2 dose

– Bupropion (Wellbutrin) Vanlafaxine (Effexor) SSRIsSSRIs

– No Fluoxetine (Prozac) inhibits liver enzymes & No Fluoxetine (Prozac) inhibits liver enzymes & ↑ ↑ serum levels of other medsserum levels of other meds

– Paroxetine (Paxil) Citalopram (Celexa)

AnticonvulsantsAnticonvulsants ↓ ↓ Impulsivity & aggressionImpulsivity & aggression Valproic Acid (Depakote) & Carbamazapine (Tegretol)Valproic Acid (Depakote) & Carbamazapine (Tegretol)

Multidisciplinary ApproachMultidisciplinary Approach Speech TherapistSpeech Therapist

– Restore swallowingRestore swallowing– Delay aphasiaDelay aphasia

Physical TherapistPhysical Therapist– ““Use it or lose it”Use it or lose it”– Retain strength & memoryRetain strength & memory– ImproveImprove large & fine motor skills large & fine motor skills

Occupational TherapistOccupational Therapist– Sensory & Brain stimulationSensory & Brain stimulation– ADL & Self-care training programADL & Self-care training program

Multidisciplinary ApproachMultidisciplinary Approach Social WorkerSocial Worker

– Individual & Group TherapyIndividual & Group Therapy– Family SupportFamily Support

Sandwich generationSandwich generation ↑ ↑ Caretaking demands & multiple rolesCaretaking demands & multiple roles Coping with feelings of personal lossCoping with feelings of personal loss Anticipatory GrievingAnticipatory Grieving Assistance from all relevant agenciesAssistance from all relevant agencies Alzheimer's Alzheimer's AssociationAssociation

– Community ResourcesCommunity Resources Respite careRespite care Day Care CentersDay Care Centers Residential FacilitiesResidential Facilities Specialized Alzheimer’s unitsSpecialized Alzheimer’s units