Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

CHAPTER 17CHAPTER 17

Cognitive DisordersCognitive Disorders

1

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

EtiologyEtiology DeliriumDelirium

An underlying systemic illness, including An underlying systemic illness, including infection, and endocrine disorder, trauma, infection, and endocrine disorder, trauma, and drug/alcohol abuseand drug/alcohol abuse

DementiaDementia Classified as to the cause or area of brain Classified as to the cause or area of brain

damagedamage

Amnestic disordersAmnestic disorders Head trauma, hypoxia, encephalitis, Head trauma, hypoxia, encephalitis,

thiamine deficiency, and substance abusethiamine deficiency, and substance abuse2

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Differentiating Types of Cognitive Differentiating Types of Cognitive DisordersDisorders

DeliriumDelirium Acute confusional state characterized by Acute confusional state characterized by

disruptions in thinking, perception, & memorydisruptions in thinking, perception, & memory DementiaDementia

Chronic state characterized by declines in Chronic state characterized by declines in multiple cognitive areas, including memorymultiple cognitive areas, including memory

Amnestic disordersAmnestic disorders Uncommon cognitive disorder characterized by Uncommon cognitive disorder characterized by

amnesiaamnesia

3

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4

Delirium Delirium – – Clinical PictureClinical Picture• Disturbances in consciousnessDisturbances in consciousness• Change in cognitionChange in cognition• Develops over a short period of timeDevelops over a short period of time• Common in hospitalized patients, especially older Common in hospitalized patients, especially older

adultsadults• Always secondary to another physiological Always secondary to another physiological

conditioncondition• Is a transient disorderIs a transient disorder• If underlying condition corrected, complete If underlying condition corrected, complete

recovery should occurrecovery should occur

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5

Delirium AssessmentDelirium Assessment• Four cardinal featuresFour cardinal features

– Acute onset and fluctuating courseAcute onset and fluctuating course– InattentionInattention– Disorganized thinkingDisorganized thinking– Disturbance of consciousness Disturbance of consciousness

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6

Delirium AssessmentDelirium Assessment• Cognitive and perceptual disturbancesCognitive and perceptual disturbances

– Illusions Illusions – HallucinationsHallucinations

• Physical needsPhysical needs• Mood and physical behaviorsMood and physical behaviors• Attention spanAttention span• Reasoning Reasoning • Sleep and wake cycleSleep and wake cycle

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7

DeliriumDelirium Nursing Diagnoses Nursing Diagnoses

• Risk for injuryRisk for injury• Acute confusionAcute confusion• Deficient fluid volumeDeficient fluid volume• Insomnia, Sleep deprivationInsomnia, Sleep deprivation• Impaired verbal communicationImpaired verbal communication• FearFear• Self-care deficitSelf-care deficit• Disturbed thought processDisturbed thought process

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8

DeliriumDeliriumOutcomes IdentificationOutcomes Identification

• Patient will return to premorbid level of Patient will return to premorbid level of functioning.functioning.

• Patient will remain safe and free from Patient will remain safe and free from injury while in the hospital.injury while in the hospital.

• Patient will be oriented to time, place, Patient will be oriented to time, place, and person.and person.

• Patient will be free from falls and injury.Patient will be free from falls and injury.

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9

Delirium ImplementationDelirium Implementation• Prevent physical harm due to confusion, Prevent physical harm due to confusion,

aggression, or fluid and electrolyte aggression, or fluid and electrolyte imbalance.imbalance.

• Perform comprehensive nursing Perform comprehensive nursing assessment to aid in identifying cause.assessment to aid in identifying cause.

• Assist with proper health management to Assist with proper health management to eradicate underlying cause.eradicate underlying cause.

• Use supportive measures to relieve Use supportive measures to relieve distress. distress.

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Interventions for DeliriumInterventions for Delirium Introduce self and call client by name at each Introduce self and call client by name at each

contactcontact Maintain face-to-face contactMaintain face-to-face contact Use short, concrete phrasesUse short, concrete phrases Keep room well litKeep room well lit Keep environmental noise lowKeep environmental noise low Set limits on behaviorSet limits on behavior 1:1 staffing as needed1:1 staffing as needed

10

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11

Delirium EvaluationDelirium Evaluation

• Patient will remain safe.Patient will remain safe.

• Patient will be oriented to time, Patient will be oriented to time, place, and person by discharge.place, and person by discharge.

• Underlying cause will be treated and Underlying cause will be treated and ameliorated. ameliorated.

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12

DementiaDementia• Progressive deterioration of cognitive Progressive deterioration of cognitive

functioning and global impairment of functioning and global impairment of intellectintellect

• No change in consciousnessNo change in consciousness• Difficulty with memory, thinking, and Difficulty with memory, thinking, and

comprehensioncomprehension• Majority of dementias are irreversibleMajority of dementias are irreversible

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13

DementiaDementiaPrimary Versus SecondaryPrimary Versus Secondary

• PrimaryPrimary– IrreversibleIrreversible– ProgressiveProgressive– Not secondary to any other diseaseNot secondary to any other disease– Example: Alzheimer's diseaseExample: Alzheimer's disease

• SecondarySecondary– Result of some other pathological processResult of some other pathological process– Example: AIDS-related dementiaExample: AIDS-related dementia

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14

Alzheimer’s Disease EtiologyAlzheimer’s Disease Etiology• Biological factorsBiological factors

– Cerebral atrophyCerebral atrophy– Neurofibrillary tanglesNeurofibrillary tangles– Neuritic plaquesNeuritic plaques

• GeneticGenetic Dementia of Alzheimer’s typeDementia of Alzheimer’s type Dementia from Huntington’s diseaseDementia from Huntington’s disease Dementia from Pick’s diseaseDementia from Pick’s disease

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Alzheimer’s Disease EtiologyAlzheimer’s Disease Etiology• Environmental factorEnvironmental factor

• Dementia from Creutzfeldt–Jakob diseaseDementia from Creutzfeldt–Jakob disease

15

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16

Nursing ProcessNursing Process• AssessmentAssessment

– ConfabulationConfabulation– Perseveration Perseveration

• Cardinal symptoms observed in ADCardinal symptoms observed in AD– Amnesia or memory impairmentAmnesia or memory impairment– AphasiaAphasia– ApraxiaApraxia– AgnosiaAgnosia– Disturbances in executive functioningDisturbances in executive functioning

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing ProcessNursing Process Poor judgmentPoor judgment Decline in previous abilitiesDecline in previous abilities

17

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18

Stages ofStages ofAlzheimer's DiseaseAlzheimer's Disease

• Stage 1 (Mild) – forgetfulnessStage 1 (Mild) – forgetfulness

• Stage 2 (Moderate) – confusionStage 2 (Moderate) – confusion

• Stage 3 (Moderate to Severe) – unable Stage 3 (Moderate to Severe) – unable to identify familiar objects or peopleto identify familiar objects or people

• Stage 4 (Late) – end-stageStage 4 (Late) – end-stage

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19

Alzheimer’s DiseaseAlzheimer’s Disease Nursing Diagnoses Nursing Diagnoses

• Risk for injuryRisk for injury• Impaired verbal communicationImpaired verbal communication• Impaired environmental interpretation Impaired environmental interpretation

syndromesyndrome• Impaired memoryImpaired memory• Confusion Confusion • Caregiver role strainCaregiver role strain

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20

Alzheimer's DiseaseAlzheimer's Disease Outcomes Identification Outcomes Identification

• Areas to targetAreas to target– InjuryInjury– CommunicationCommunication– Agitation levelAgitation level– Caregiver role strainCaregiver role strain– Impaired environmental interpretation: Impaired environmental interpretation:

chronic confusionchronic confusion– Self-care needsSelf-care needs

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21

Alzheimer's DiseaseAlzheimer's DiseasePlanningPlanning

• Geared towards person’s immediate Geared towards person’s immediate needsneeds

• Identify level of functioning Identify level of functioning • Assess caregivers’ needs Assess caregivers’ needs • Plan and identify appropriate Plan and identify appropriate

community resources community resources

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22

Alzheimer's Disease Alzheimer's Disease ImplementationImplementation

• Maintain optimal nutritionMaintain optimal nutrition• Counseling and communication techniquesCounseling and communication techniques• Health teaching and health promotionHealth teaching and health promotion• Referral to community supportsReferral to community supports• Structure the environment to support Structure the environment to support

cognitive functionscognitive functions• Pharmacological interventionsPharmacological interventions

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23

Pharmacological InterventionsPharmacological Interventionsfor Alzheimer’s Diseasefor Alzheimer’s Disease

• Tacrine (Cognex)Tacrine (Cognex)• Donepezil (Aricept)Donepezil (Aricept)• Rivastigmine (Exelon)Rivastigmine (Exelon)• Galantamine (Razadyne)Galantamine (Razadyne)• Memantine (Namenda)Memantine (Namenda)

Slows the rate of cognitive declineSlows the rate of cognitive decline

Potent acetylcholinesterase inhibitorsPotent acetylcholinesterase inhibitors

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Common Medications for Cognitive Common Medications for Cognitive DisordersDisorders

Dementia with Lewy BodiesDementia with Lewy Bodies Escitalopram (Lexapro)Escitalopram (Lexapro)Reduce symptoms of depression when presentReduce symptoms of depression when present

Pick’s DiseasePick’s Disease Valproic Acid (Depakote)Valproic Acid (Depakote)Reduce problematic mood swings and agitated behaviorReduce problematic mood swings and agitated behavior

Vascular Dementia with psychosisVascular Dementia with psychosis Quetiapine (Seroquel)Quetiapine (Seroquel)Reduce or eliminate delusions and hallucinationReduce or eliminate delusions and hallucination

24

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Amnestic DisorderAmnestic Disorder Characterized by short-and long-term Characterized by short-and long-term

memory deficitsmemory deficits Inability to recall previously learned Inability to recall previously learned

information or past eventsinformation or past events Inability to learn new materialsInability to learn new materials Cofabulation, apathy, bland affectCofabulation, apathy, bland affect Amnestic disorder NOS: not enough Amnestic disorder NOS: not enough

supporting evidence to link a cause to the supporting evidence to link a cause to the amnesia (medical or substance)amnesia (medical or substance)

25

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

DepressionDepression Depression can be masked by symptoms Depression can be masked by symptoms

suggestive of dementiasuggestive of dementia The term pseudodementia is used to The term pseudodementia is used to

describe the reversible cognitive describe the reversible cognitive impairments seen in depressionimpairments seen in depression

Pseudodementia is characterized by an Pseudodementia is characterized by an abrupt onset, rapid clinical course, and abrupt onset, rapid clinical course, and client complaints about cognitive failures client complaints about cognitive failures

26

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Caregiver DifficultiesCaregiver Difficulties Wandering behaviors Wandering behaviors Sundowning disorientation Sundowning disorientation Activities of Daily LivingActivities of Daily Living Medication managementMedication management Burnout and fatigueBurnout and fatigue

27

Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc.

Caregiver ResourcesCaregiver Resources Family meetingsFamily meetings Alzheimer’s Disease and Related Alzheimer’s Disease and Related

Disorders Association (ADRDA) Disorders Association (ADRDA) Caregiver support groupsCaregiver support groups Identify community resourcesIdentify community resources ID bracelet for the client ID bracelet for the client

28