Chapter 21 Cognitive Impairment Cognitive Impairment  Describes disturbances in cognitive function.

 Disturbances in memory, orientation, and concentration  Other disturbances of cognition affect intelligence, judgment, learning abilities, perception, problem solving, psychomotor abilities, reaction time, and social intactness. *Withdraw from social events a lot of times Three D’s of Cognitive Impairment  The D’s of cognitive impairment are:  Dementia  Delirium  Depression  All frequently affect older adults.  Although not normal consequences of aging, these impairments increase with age.  Pathological progression of the three D’s requires urgent assessment and intervention. Comprehensive Evaluation  Complete assessment (rule out possible causes- neuro- physical examination is very important)  Laboratory workup  Need to rule out possible causes for cognitive impairments  Neuropsychological examination  Interview with family and client  Observation  Functional assessment  Computed tomography (CT), magnetic resonance imaging (MRI), and electrocardiography (ECG) Considerations in Cognitive Assessment     Poor performance on tests of memory cause anxiety. Assessments need to be performed with hearing aids and glasses, if needed. Environment should be free of distractions when assessment is performed. Assessment is best completed immediately upon wakening.

Always know baseline of pt to be able to distinguish something out of the ordinary

Symptoms develop over a short time (hours to days). Symptoms fluctuate over the course of the day and are worse in the evening.  Is associated with lasting cognitive impairment and psychiatric problems that may persist after discharge.Difficulties with tests of memory can cause them to have anxiety Be sure they’re wearing their glasses/ hearing aids Environment free of distractions as much as possible Delirium     Onset may be acute or subacute. Symptoms include disturbances in consciousness and attention.  Is a stressor for nurses and family. an accurate diagnosis is needed. . and perpetual disturbances accompanied by delusional (paranoid) thoughts and behaviors. consequently. memory deficits.  Is reversible. *Always look at what the medications are of the pt FIRST b/c it could be causing their delirium  if caused by medication. and let physician know they’re on a new medicationtheir cognition can reverse itself if they’re taken off the med Consequences of Delirium  Is a high priority nursing challenge for all nurses who care for older adults. Causes of Delirium  Delirium results from interaction of predisposing factors:  Cognitive impairment  Severe illness  Sensory impairment  Medications  Procedures  Restraints  Iatrogenic events  A highly vulnerable older individual requires fewer precipitating factors to develop delirium.

time? Has their cognition deteriorated or improved? Are they are analgesics or sedatives? Dementia  Onset is gradual and slow.Lack of Recognition of Delirium      Inadequate education about delirium Lack of formal assessment methods View that delirium is not essential to the client’s well being Failure to recognize Failure to initiate timely interventions. **What’s their orientation to person. frontotemporal lobe dementia. 2nd edition (MMSE-2)  Confusion assessment method  Neelon and Champagne (NEECHAM) Confusion Scale  Determine the client’s mental status.  Some degenerative dementia conditions are:  Alzheimer’s.  Is irreversible.makes delirium worse Implications for Gerontological Nursing and Healthy Aging  Instruments used for assessment include:  **Mini–mental state examination.  Pattern of decline is steady without alterations in consciousness. place. and other less common dementias Alzheimer’s disease: Sometimes not fully diagnosed until an autopsy is performed Incidence and Prevalence of Dementia  Is the most disabling and burdensome (upon the adult & the family) of chronic conditions in older adults. . dementia with Lewy bodies  Parkinson disease dementia.  Intervention begins with prevention.  Sedatives or analgesics may reduce the incidence or duration of delirium. and its progression causes memory impairment and a loss of intellectual abilities severe enough to interfere with daily life.

most common. developing after 60 years of age Protective Roles of Psychosocial Factors  Behaviors that possibly cause protective abilities include:  Higher education  Regular exercise  Healthy diet  Intellectually challenging leisure activities  Active socially integrated lifestyle *These are factors to HELP a person Diagnosis of Alzheimer Disease  Three stages of Alzheimer disease are:  Preclinical  Mild cognitive impairment  Dementia as a result of Alzheimer pathologic characteristics  Goal is to provide standards for research and practice that further advance the field for early detection and treatment.  Potential risks include vascular risk factors. developing after 60 years of age. (more research needed) .  Is the third most expensive medical condition. dyslipidemia. Alzheimer Disease  Is the most common form of dementia. Were previously living independently – now need a caregiver or need to move int o a living facility. hypertension. cigarette smoking. obstructive sleep apnea. etc. late onset is the most common.  Societal costs are related to the disease. Frightening implications face the client and family.  Types include early onset and late onset. and cerebrovascular lesions. diabetes. Early onset OR Late onset. midlife obesity.

the nurse needs to be able to differentiate between delirium and depression in an older adult The way to distinguish is a person’s orientation (If the orientation decreases then the person is suffering from some type of delirium) Very important to approach their hygienic care very carefully. can’t find their way back Progressively Lowered Stress Threshold Model  Progressively lowered stress threshold (PLST) is the first model used to plan and care for those with dementia. setting needs to be CALM.continue to decline Wandering= most dangerous. predictable environment.explain each step as you go along and be certain to keep them covered as much as possible to respect their privacy (They will fight you. because they don’t understand what’s going on) Milieu: environment. **When assessing a pt. **What is the PLAN that can be done to keep this patient with dementia safe This care can decrease the stress and the stress of the caregiver. dementia-compromised behavior (NDB) model provides the framework for studying and understanding behavioral symptoms of dementia. and health promotion  Assessment 6 months after diagnosis and anytime a change in behavior occurs  Administration of cholinesterase inhibitors  Residency in an Alzheimer care unit Common Care Concerns     Communication Behavior concerns Activities of daily living (ADLs) care.for a person experiencing delirium . and provides safe environment Need-Driven.Treatment  Ongoing monitoring of disease progression.  Interventions are performed to minimize behaviors or actions.  Care decreases the stressors and provides a safe. regular health maintenance. family member. Dementia-Compromised Behavior Model  Need-driven.

interact with person individually. medication use. medications Pg 323 box 21-7 Useful strategies for communicating box 21-7 – always introduce self and explain WHY your there.  Behavioral symptoms include fear. what it is that you’re going to be doing When a person happens to have cognitive impartment simplification strategies are important: Give 1 step directions (1 step at a time.what’s their mental status baseline . diet. what’s their functional abilities.what is the total number of medications If more than 6 meds. what’s their living conditions. fatigue.  Bathing can be perceived as an attack by the client. dementia with lewy bodies 21-3 table. they could be affecting one another and causing the delirium Most important thing about delirium is to KNOW the pt’s baseline. depression level. discomfort.  Comprehensive assessment and the use of medications are treatments of choice. unfamiliar sounds and people. depression. Parkinson’s disease dementia.D. illness. mental activity.risk factors for A. and need for autonomy and control.21-1 table pg 310 – delirium. family history. will most frequently come across: Alzheimer’s disease dementia. depression. reduce distractions Implications for Gerontological Nursing and Healthy Aging  Client assessment is conducted.  Behavioral changes occur with distressing conditions such as constipation and urinary tract infections. vascular dementia. give time to respond. *explain step by step to the patient Caregivers  Stress of the caregiver is caused by:  Fewer health-promoting behaviors  Higher depression and anxiety rates  Higher morbidity and mortality rates  Sleep problems . and alcohol use?? Pg 317 box 21-2 – dementia types As a nurse. speak slowly). What’s their age. and dementia differentiation (Precipitating factors 21-1 box) #1 thing that can cause dementia.

 Higher number of illness-related symptoms  Caregiver plays the roles of magician. carpenter. and jester. Sleep problems can be caused by fear of the pt wandering Caregiver fatigue can lead to unintentional abuse . detective.