NEUROCOGNITIVE DISORDERS DEFINED

deficits in a person’s thought processes or memory that are due to brain dysfunction

represent a significant decline from the previous level of functioning

TYPES OF NEUROCOGNITIVE DISORDERS

Dementia (discussed in detail later)

Delirium is the most common cognitive disorder, and also the least debilitating Unlike dementia, originates outside the central nervous system and symptoms

fluctuate and are short-term

Amnestic disorders feature impairments of memory that do not include any other type of cognitive

impairment relatively uncommon associated with the effects of substance abuse and medical conditions. Transient forms from epilepsy, side effects of electro-convulsive therapy and

some medications, thiamin deficiency, and hypoxia (temporary oxygen loss)

Permanent amnesia may result from head trauma, carbon monoxide poisoning, cerebral infarction,

hemorrhage and brain swelling related to herpes simplex

SYMPTOMS OF DEMENTIA

Memory impairment is always required to make a diagnosis of dementia.

Aphasia - loss of the ability to use wordsApraxia - loss of the ability to use common

objects correctlyAgnosia - loss of the ability to understand

sound and visual inputLoss of executive functioning - an inability to

plan, organize, follow sequences, and think abstractly.

http://www.youtube.com/watch?v=imQvmxx_mMQ

PREVALENCE

rare among children and adolescents but can occur at any age as the result

of certain medical conditions

1.4% to 1.6% for persons aged 65-69 years, rising to 16% to 25% for

persons over 85

Average age of diagnosis – 80

VASCULAR DEMENTIA

a progressive, irreversible cognitive disorder caused by blocked blood vessels to the brain due to cerebral infarction or hemorrhage

accounts for 10 to 15% of all types of dementia

Depression is a relatively frequent complication of VaD, more so than with Alzheimer’s disease (27% of people with VaD experience major depression)

Alzheimer’s disease

50-60% of those with dementia

Autopsies show that brain cells in the cortex and hippocampus, areas that are responsible for learning, reasoning, and memory, have become clogged with two abnormal structures:

Neurofibrillary tangles - twisted masses of protein fibers inside cells or neurons

plaques - deposits of a sticky protein called amyloid that is surrounded by debris from deteriorating neurons

duration of its course is unpredictable, although 5-10 years most common

Unknown cause and no cure, although meds may slow course

Behavioral problems – reason

people seek txPerceptual disturbances including delusions,

hallucinations, and the misidentification of people

Mood disturbances

Wandering and other dangerous or careless behavior

Agitation or rage

Sleep disturbances

Distressing repetitive behavior

Inappropriate sexual behavior

Incontinence

Refusal to eat

COMORBIDITY

40–50% of persons with dementia experience symptoms of anxiety and

depression

10–20% have a major depressive disorder

30–40% have delusions (often persecutory)

20–30% experience hallucinations (primarily with Alzheimer’s)

DIAGNOSIS

Medical diagnosis

Not positively identified by medical examination and tests, ruled “in” if

other possible conditions can’t account for the symptoms

quality of person’s life

determined by:quality of health care

family support provided him or her

CHALLENGES TO FAMILIES

1/3 live in nursing homes

monitor the client’s changing levels of dependence and independence as the disease progresses.

He or she must care for the loved one, preserve the client’s dignity, and balance his or her own limits on time, energy, and patience.

The stress to family member caretakers may be heightened by their fears of loss, guilt over not being an adequate caregiver, ambivalence about the caregiver role, and fears about their own mortality.

MEDICATION

cholinesterase inhibitors, which work by inhibiting the breakdown of a key brain chemical, acetylcholine

Tacrine (Cognex), 1st drug approved by the FDA, but intolerable side effects

The FDA has approved three other drugs since 1994 that are intended to have a mild to moderate effect on its presentation

donepezil, rivastigmine (Exelon), and galantamine (Reminyl)

may improve cognitive function and global level of functioning in mild to moderate Alzheimer’s disease

OTHER MEDICATIONS

may be effective for treating the symptoms of psychosis, agitation, and

depression

Lower doses for the elderly because of slower metabolism and rates of

clearance through the kidneys

PRACTICE GUIDELINES

Establish and maintain an alliance with the client and family

Arrange and participate in a diagnostic evaluation, and link the client with resources for any needed medical care.

Assess and monitor the client’s noncognitive (emotional and behavioral) mental status.

Monitor provisions for the client’s safety and intervene when appropriate

Intervene to decrease the hazards of the client’s wandering behavior (if applicable).

Advise the client and family concerning driving and other client activities that put people at risk.

Educate the client and family about the illness and available interventions

Advise the family regarding sources of care and support

Psychoeducation

Respite care

Assess and refer the family for assistance with any related financial and legal issues.

PSYCHOSOCIAL INTERVENTIONS

behavioral management

staff training on behavioral management

cognitive stimulation

reminiscence therapy

Creative arts therapies

Recreational therapies