chapter 21 cognitive disorders

Chapter 21 Cognitive Disorders

Cognition involves the brain’s ability to process, retain, and use information.

Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory.

Disruption of these functions impairs the person’s ability to make decisions, solve problems, interpret the environment, and learn new information.

DeliriumDelirium

Delirium: a syndrome that involves disturbance of consciousness accompanied by a change in cognition

• Acute and fluctuating

• Difficulty paying attention, distractibility, and disorientation

• Sensory disturbances include illusions, misinterpretations, hallucinations

• Disturbances in sleep/wake cycle, anxiety, fear, irritability, euphoria, apathy

Delirium (cont’d)Delirium (cont’d)•Risk factors: hospitalization for general

medical conditions, older acutely ill clients, severe physical illness, older age, and baseline cognitive impairment

•Etiology: almost always results from an identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal

Cultural Considerations Cultural Considerations

• People from different cultural backgrounds may not be familiar with the information requested to assess memory

• Other cultures may consider orientation to placement and location differently

• Some cultures and religions, such as Jehovah’s Witnesses, do not celebrate birthdays, so clients may have difficulty stating their date of birth

Treatment and PrognosisTreatment and Prognosis

• Treatment of the underlying medical condition will usually resolve delirium

• Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury

• Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium

Psychopharmacology and Other Medical Treatment Psychopharmacology and Other Medical Treatment • If quiet and resting, no medication needed

for delirium

• If experiencing psychomotor agitation, sedation with an antipsychotic may prevent inadvertent self-injury

• Delirium induced by alcohol withdrawal is treated with benzodiazepines

• Adequate food and fluid

• Physical restraints only when necessary

Application of the Nursing Process: DeliriumApplication of the Nursing Process: Delirium

Assessment

• History: medical illness, prescribed medications, alcohol, illicit drugs, and over-the-counter medications

• General appearance and motor behavior: restless, picking at covers, agitated, getting out of bed, or sluggish and lethargic; speech is less coherent as delirium worsens

Assessment (cont’d)

• Mood and affect: client has rapid and unpredictable mood shifts with wide range of emotions

• Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition

• Sensorium and intellectual processes: sensory misperceptions, disorientation, confusion, lack of attention and concentration

Application of the Nursing Process: Delirium (cont’d)Application of the Nursing Process: Delirium (cont’d)

Assessment (cont’d)• Judgment and insight: impaired judgment, varied

insight

• Roles and relationships: usually no long-term effect unless previous problems existed

• Self-concept: frightened or feel threatened; may feel helpless or powerless; may feel guilt, shame, and humiliation

• Physiologic and self-care considerations: trouble sleeping, may ignore body cues such as hunger, thirst, or the urge to urinate or defecate


Data Analysis

Nursing diagnoses may include:• Risk for Injury

• Acute Confusion

• Disturbed Sensory Perception

• Disturbed Thought Processes

• Disturbed Sleep Pattern

• Risk for Deficient Fluid Volume

• Risk for Imbalanced Nutrition: Less Than Body Requirements


Outcomes

The client will:

• Be free of injury

• Demonstrate increased orientation and reality contact

• Maintain an adequate balance of activity and rest

• Maintain adequate nutrition and fluid balance

• Return to optimal level of functioning (predelirium)


Intervention

•Promoting safety

•Managing confusion

•Promoting sleep and nutrition


Evaluation

Has the underlying cause of delirium been successfully treated?

Has the client returned to his or her previous level of functioning?

Does the client and caregiver or family understand what health care practices are necessary to avoid a recurrence (this may involve monitoring a chronic health condition, careful use of medications, or abstaining from alcohol or other drugs)?


Community-Based Care: DeliriumCommunity-Based Care: Delirium

If clients continue to experience cognitive problems, referrals may be necessary for:

– Home health

– Visiting nurses

– Rehabilitation program

– Adult day care

– Residential care

– Support groups

DementiaDementia• Dementia involves multiple cognitive

deficits, primarily memory impairment, and at least one of the following: – Aphasia

– Apraxia

– Agnosia

– Disturbance in executive functioning

• Dementia is progressive unless the underlying cause is treatable, such as vascular dementia, which is rare

Onset and Clinical CourseOnset and Clinical Course• Mild (excessive forgetfulness, difficulty finding

words, loses objects, anxiety about loss of cognitive abilities)

• Moderate (confusion, progressive memory loss, can’t do complex tasks, oriented to person and place, recognizes familiar people; by the end of this stage requires assistance and supervision)

• Severe (personality and emotional changes, delusional, wanders at night, forgets names of spouse and children, requires assistance with activities of daily living)

EtiologyEtiology

• Alzheimer’s disease

• Vascular dementia (may have sudden onset; progression may be arrested with treatment)

• Pick’s disease

• Creutzfeldt-Jakob disease

• Dementia due to HIV

• Parkinson’s disease

• Huntington’s disease

• Dementia due to head trauma

Cultural ConsiderationsCultural Considerations

•Take into account whether client would be expected to know certain information, such as names of past presidents

•Recognize differing beliefs about elders

Treatment and PrognosisTreatment and Prognosis

•Identify and treat underlying cause whenever possible

•No therapies have been found to reverse or retard degenerative dementias

•Progressive deterioration of physical and mental abilities until death

Treatment and Prognosis (cont’d)Treatment and Prognosis (cont’d)

• Acetylcholine precursors, cholinergic agonists, and cholinesterase inhibitors such as tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) temporarily slow the progress of dementia

• Symptomatic treatment of behaviors such as delusions, hallucinations, outbursts, and labile moods, which vary among clients

Application of the Nursing Process: DementiaApplication of the Nursing Process: DementiaAssessment• History: may be unable to provide an accurate and

thorough history; interview family, friends, or caregivers

• General appearance: aphasia, perseveration, slurring, eventual loss of language

• Motor behavior: apraxia, cannot imitate demonstrated tasks, finally gait disturbance making unassisted ambulation unsafe, then impossible


• May demonstrate uninhibited behavior: inappropriate jokes, sexual comments, undressing in public, profanity; familiarity with strangers

• Mood and affect: initially anxious and fearful over lost abilities, labile moods, emotional outbursts, catastrophic emotional responses; verbal or physical aggression possible; may become emotionally listless, apathetic, withdrawn

Application of the Nursing Process: Dementia (cont’d)Application of the Nursing Process: Dementia (cont’d)

Assessment (cont’d)• Thought processes and content: initially loses

ability to think abstractly; cannot solve problems; cannot generalize knowledge from one situation to another; later, delusions of persecution are common

• Sensorium and intellectual processes: initially memory deficits that worsen over time; confabulation to fill in memory gaps; agnosia; cannot write or draw simple objects; inability to concentrate; chronic confusion, disorientation (eventually even to person); visual hallucinations common



• Judgment and insight: initially recognizes he or she is losing abilities, and then insight fades altogether; judgment impaired due to cognitive deficits; worsens over time; at risk for wandering, getting lost, injuring self, unable to perceive harm



• Self-concept: initially client is frustrated at losing things or forgetting, sad about “getting old”; sense of self deteriorates until client doesn’t recognize own reflection in mirror

• Roles and relationships: can no longer work, cannot fulfill roles at home, cannot attend social events, eventually confined to home; family members often become caregivers but feel loved one has become a stranger



• Physiologic and self-care considerations: disturbances in sleep/wake cycle, ignoring body cues to eat, drink, urinate, etc.; lose abilities to do personal hygiene, even feeding self


Data Analysis Nursing diagnoses include:Data Analysis Nursing diagnoses include:

• Risk for Injury

• Disturbed Sleep Pattern

• Risk for Deficient Fluid Volume

• Risk for Imbalanced Nutrition

• Chronic Confusion

• Impaired Environmental Interpretation Syndrome

• Impaired Memory

• Impaired Socialization

• Impaired Verbal Communication

• Ineffective Role Performance


Outcomes

The client will:• Be free of injury

• Maintain an adequate balance of activity and rest, nutrition, and hydration and elimination

• Function as independently as possible given his or her limitations

• Feel respected and supported

• Remain involved in his or her surroundings

• Interact with others


Intervention

•Promoting safety

•Promoting adequate sleep, nutrition, hygiene, and activity

•Structuring the environment and routine


Intervention (cont’d)

•Providing emotional support– Supportive touch

•Promoting interaction and involvement– Reminiscence therapy

– Distraction

– Time away

– Going along


Evaluation

Is the client maintaining independence to the greatest degree possible considering the stage of cognitive impairment?

Are family members and caregivers able to carry out their changing roles as the client’s condition worsens?


Community-Based Care: DementiaCommunity-Based Care: Dementia

Many persons with dementia are in the community for most of their lives:

•Family homes

•Adult day care centers

•Residential facilities

•Specialized Alzheimer’s units

Mental Health PromotionMental Health Promotion

•Research continues to identify risk factors for dementia (elevated levels of plasma homocysteine)

•Regular participation in brain-stimulating activities

Trend toward caring for family members with dementia at home

Caregivers need:• Education about dementia and care needed by client

• Help dealing with own feelings of loss

• Respite to care for own needs

• Support groups

• Assistance from agencies

• Support to maintain a personal life

Role of the CaregiverRole of the Caregiver

Related DisordersRelated Disorders

Amnestic Disorder• Disturbance in memory resulting from the

physiologic effects of a general medical condition (stroke, head injury, carbon monoxide poisoning, chronic alcohol ingestion)

• Confusion, disorientation, and attentional deficits are common

• Clients do NOT have the multiple cognitive deficits seen in dementia such as aphasia, apraxia, agnosia, and impaired executive functions

Related Disorders (cont’d)Related Disorders (cont’d)

Korsakoff’s Syndrome• Alcohol-induced amnestic disorder resulting from a

chronic thiamine or vitamin B deficiency

• Confusion, disorientation, and attentional deficits are common

• Clients do NOT have the multiple cognitive deficits seen in dementia such as aphasia, apraxia, agnosia, and impaired executive functions

Related Disorders (cont’d)Related Disorders (cont’d)

The main difference between dementia and amnestic disorders is that once the underlying medical cause is treated or removed, the client’s condition no longer deteriorates.

However, in cases of chronic alcohol ingestion or malnutrition, clients can have persistent impairment of memory and attention with minimal improvement.

Self-Awareness IssuesSelf-Awareness Issues

•Inability to “teach” a client with dementia

•Feelings of frustration or hopelessness

•Knowledge that there is progressive deterioration until death, with no hope for improvement

chapter 21 cognitive disorders

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