Cognitive Disorders

Introduction

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

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

- These cognitive abilities are essential for many important tasks, including making decisions, solving problems,
interpreting the environment, and learning new information.

cognitive disorder - a disruption or impairment in these higher level functions of the brain.

- have devastating effects on the ability to function in daily life.

- They can cause people to forget the names of immediate family members, be unable to perform daily household tasks,
and neglect personal hygiene.
Cognitive Function

- The brain integrates, regulates, initiates, and controls functions in the entire body.

- The processes of thinking, remembering, and learning occur in different areas of the brain.

For example, the frontal lobe organizes and classifies information; the parietal lobe processes sensory input;
the temporal lobe synthesizes auditory, visual, and somatic input into thought and memory; and the occipital lobe
controls visual information that is received and processed through the retina.
 Different parts of the brain have different functions

• The frontal lobes of the cerebrum allow us to solve problems, plan

ahead, understand the behavior of others, and restrain our
impulses.

• The corpus callosum passes information from one side of the

brain to the other.

• The parietal areas control hearing, speech, and language.

• The amygdala directs our emotional responses.

• The hippocampus makes it possible to recall recent experiences

and new information.

• The cerebellum regulates balance, body movements, coordination,

and the muscles used in speaking
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) previously
categorized adult cognitive disorders as dementia, delirium, and amnestic disorders.
 DELIRIUM
is a syndrome that involves a disturbance of consciousness accompanied by a change in cognition.

usually develops over a short period, sometimes a matter of hours, and fluctuates, or changes, throughout the course of the
day.

S/SX:

- difficulty paying attention

- easily distracted and disoriented

- may have sensory disturbances (illusions, misinterpretations, or hallucinations)

- electrical cord on the floor may appear to them as a snake (illusion)

- They may mistake the banging of a laundry cart in the hallway for a gunshot (misinterpretation)
S/SX:

- They may see “angels” hovering above when nothing is there (hallucination)

- disturbances in the sleep–wake cycle

- changes in psychomotor activity

- emotional problems (anxiety, fear, irritability, euphoria, or apathy)

Risk factors:

- increased severity of physical illness

- older age

- hearing impairment

- decreased food and fluid intake

- Medications

- baseline cognitive impairment such as that seen in dementia

Etiology:
CULTURAL CONSIDERATIONS

Other cultures may consider orientation to placement and location differently.

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

The nurse should not mistake failure to know such information for disorientation.
 Treatment and Prognosis

✔ primary treatment for delirium is to identify and treat any causal or contributing medical conditions.

Psychopharmacology

- Sedation - to prevent inadvertent self-injury may be indicated

- haloperidol (Haldol) - 0.5 to 1 mg; to decrease agitation and psychotic symptoms, as well as to facilitate
sleep.

- can be administered orally, intramuscularly (IM), or intravenously (IV)

- lorazepam (Ativan) - intermediate-acting benzodiazepines; but benzodiazepines may worsen delirium,

especially in the elderly.

“The exception is delirium induced by alcohol withdrawal, which is usually treated with benzodiazepines”
 Other Medical Treatment

- Adequate nutritious food and fluid intake speed recovery.

- IV fluids or even total parenteral nutrition ~ may be necessary if a client’s physical condition has deteriorated and he or
she cannot eat and drink.

❖ physical restraints - may be necessary = so that needed medical treatments can continue if the patient is agitated.

✔ Restraints are used only when necessary and stay in place no longer than warranted because they may increase the
client’s agitation.
 Drugs causing Delirium

Anesthesia

Anticonvulsants

Anticholinergics

Antidepressants

Antihistamines

Antihypertensives

Antineoplastics

Antipsychotics

Aspirin

Barbiturates

Benzodiazepines
 General Appearance and Motor Behavior

Clients with delirium often have a disturbance of

psychomotor behavior.

They may be restless and hyperactive, frequently

picking at bed clothes or making sudden,
uncoordinated attempts to get out of bed.

clients may have slowed motor behavior, appearing

sluggish and lethargic with little movement.
 NURSING CARE PLAN: DELIRIUM
Nursing Diagnosis:

Acute Confusion: Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop
over a short period of time.

ASSESSMENT DATA

• Poor judgment

• Cognitive impairment

• Impaired memory

• Lack of or limited insight

EXPECTED OUTCOMES

Immediate

The client will

• Be free of injury throughout hospitalization.

• Engage in a trust relationship with staff and caregiver within 24 hours.

• Increase reality contact within 24 to 48 hours.

• Cooperate with treatment within 8 to 24 hours.

Stabilization

The client will

• Establish or follow a routine for activities of daily living (ADLs).

• Demonstrate decreased confusion, illusions, or hallucinations.

• Experience minimal distress related to confusion.

• Validate perceptions with staff or caregiver before taking action.

Community

The client will

• Return to optimal level of functioning.

• Manage health conditions, if any, effectively.

• Seek medical treatment as needed.

IMPLEMENTATION
 Delirium
Speech may also be affected, becoming less coherent and more difficult to understand as delirium worsens.

Mood and Affect – (anxiety, fear, irritability, anger, euphoria, and apathy). When clients are particularly fearful and feel
threatened, they may become combative to defend themselves from perceived harm.

Thought Process and Content - Thought content in delirium is often unrelated to the situation, or speech is illogical and
difficult to understand.

Sensorium and Intellectual Processes - initial sign of delirium is an altered level of consciousness that is seldom stable
and usually fluctuates throughout the day.

- Clients are usually oriented to people but frequently disoriented to time and place. - They demonstrate decreased
awareness of the environment or situation and instead may focus on irrelevant stimuli such as the color of the
bedspread or the room.

- Noises, people, or sensory misperceptions easily distract them

illusions include clients believing that IV tubing or an electrical cord is
a snake and mistaking the nurse for a family member.

Hallucinations are most often visual; clients “see” things for which
there is no stimulus in reality.
Judgment and Insight - Judgment is impaired.

For example, they may try repeatedly to pull out IV tubing or urinary catheters; this causes
pain and interferes with necessary treatment.

- Insight depends on the severity of the delirium.

- Mild Delirium: they are confused, are receiving treatment, and will likely improve.

- Severe delirium: may have no insight into the situation.

Roles and Relationships - Clients are unlikely to fulfill their roles during the course of delirium.
Self-Concept - clients often are frightened or feel threatened.

- some awareness of the situation may feel helpless or powerless to do anything to change it.

- delirium has resulted from alcohol, illicit drug use, or overuse of prescribed medications, clients may feel guilt,
shame, and humiliation, or think, “I’m a bad person; I did this to myself.” (long term problem)

Physiological and Self-Care Considerations - disturbed sleep–wake cycles that may include difficulty falling asleep.

- daytime sleepiness, nighttime agitation

- At times, clients also ignore or fail to perceive internal body cues such as hunger, thirst, or the urge to
urinate or defecate.
The primary nursing diagnoses for clients with delirium are:

• Risk for injury

• Acute confusion

Additional diagnoses that are commonly selected based on client assessment include:

• Disturbed sensory perception

• Disturbed thought processes

• Disturbed sleep pattern

• Risk for deficient fluid volume

• Risk for imbalanced nutrition: Less than body requirements

Outcome Identification

Treatment outcomes for the client with delirium may include:

• The client will be free of injury.

• The client will demonstrate increased orientation and reality contact.

• The client will maintain an adequate balance of activity and rest.

• The client will maintain adequate nutrition and fluid balance.

• The client will return to his or her optimal level of functioning.

 NURSING INTERVENTIONS

For Delirium

• Promoting client’s safety

• Teach the client to request assistance for activities (getting out of bed, going to bathroom).

• Provide close supervision to ensure safety during these activities.

• Promptly respond to the client’s call for assistance.

• Managing client’s confusion

• Speak to the client in a calm manner in a clear low voice; use simple sentences.

• Allow adequate time for the client to comprehend and respond.

• Allow the client to make decisions as much as he or she is able to.

• Provide orienting verbal cues when talking with the client.

• Use supportive touch if appropriate.

• Controlling environment to reduce sensory overload

• Keep environmental noise to minimum (television, radio).

• Monitor the client’s response to visitors; explain to family and friends that the client may need to visit quietly
one-on-one.

• Validate the client’s anxiety and fears, but do not reinforce misperceptions.

• Promoting sleep and proper nutrition

• Monitor sleep and elimination patterns.

• Monitor food and fluid intake; provide prompts or assistance to eat and drink adequate amounts of food and
fluids.

• Provide periodic assistance to bathroom if the client does not make requests.
 • Discourage daytime napping to help sleep at night.

• Encourage some exercise during the day, such as sitting in a chair, walking in hall, or other activities the
client can manage.
Managing the Client’s Confusion

The nurse approaches these clients calmly and speaks in a clear low voice. It is important to give realistic
reassurance to clients, such as:
 Promoting Sleep and Proper Nutrition

- The nurse monitors the client’s sleep and elimination patterns and food and fluid intake.

- It may be helpful to sit with clients at meals or to frequently offer fluids.

- Family members also may be able to help clients improve their intake.

- Promoting a balance of rest and sleep is important if clients are experiencing a disturbed sleep pattern.

- Discouraging or limiting daytime napping may improve ability to sleep at night.

- It is also important for clients to have some exercise during the day to promote nighttime sleep.
 Community-Based Care

- When delirium has cleared and any other diagnoses have been eliminated,
it may be necessary for the nurse or other health care professionals to
initiate referrals to home health, visiting nurses, or a rehabilitation program
if clients continue to experience cognitive problems.
 Dementia

❖ Dementia refers to a disease process marked by progressive cognitive impairment with no change in the level of

consciousness.

- It involves multiple cognitive deficits, initially, memory impairment, and later, the following cognitive
disturbances may be seen:

• Aphasia, which is deterioration of language function

• Apraxia, which is impaired ability to execute motor functions despite intact motor abilities.

• Agnosia, which is inability to recognize or name objects despite intact sensory abilities

• Disturbance in executive functioning, which is the ability to think abstractly and to plan, initiate, sequence, monitor,
and stop complex behavior
Comparison of Delirium and Dementia
- Memory impairment is the prominent early sign of dementia.

- Clients have difficulty learning new material and forget previously learned material.

- Initially, recent memory is impaired—for example, forgetting where certain objects were placed or that food is cooking
on the stove.

- In later stages, dementia affects remote memory; clients forget the names of adult children, their lifelong occupations,
and even their names.

- Aphasia usually begins with the inability to name familiar objects or people and then progresses to speech that
becomes vague or empty with excessive use of terms such as it or thing.

- Clients may exhibit echolalia (echoing what is heard) or palilalia (repeating words or sounds over and over).
- Apraxia may cause clients to lose the ability to perform routine self-care activities such as dressing or cooking.

- Agnosia is frustrating for clients; they may look at a table and chair but are unable to name them.

- Disturbances in executive functioning are evident as clients lose the ability to learn new material, solve problems,
or carry out daily activities such as meal planning or budgeting.

Clients with dementia may also underestimate the risks associated with activities or overestimate
their ability to function in certain situations.
For example, while driving, clients may cut in front of other drivers, sideswipe parked cars, or fail
to slow down when they should.
 Onset and Clinical Course

❖ Mild: Forgetfulness is the hallmark of beginning, mild dementia.

- occasional forgetfulness experienced as part of the aging process.

- finding words, frequently loses objects, and begins to experience anxiety about these losses.

❖ Moderate: Confusion is apparent, along with progressive memory loss.

- person no longer can perform complex tasks but remains oriented to person and place.

- He or she still recognizes familiar people.

- end of this stage, the person loses the ability to live independently and requires assistance because of
disorientation to time and loss of information, such as address and telephone number.
 Onset and Clinical Course

❖ Severe: Personality and emotional changes occur.

- person may be delusional, wander at night, forget the names of his or her spouse
and children, and require assistance with ADLs.

- Most people live in nursing facilities when they reach this stage, unless extraordinary
community support is available.
 The most common types of dementia and their known or hypothesized causes
follow:

• Alzheimer disease

- is a progressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss of
speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions,
hallucinations, inattention to hygiene, and belligerence.

- evidenced by atrophy of cerebral neurons, senile plaque deposits,

and enlargement of the third and fourth ventricles of the brain.

- Risk for Alzheimer disease increases with age, and average duration

from onset of symptoms to death is 8 to 10 years.

❖ Lewy body dementia

- is a disorder that involves progressive cognitive

impairment and extensive neuropsychiatric
symptoms as well as motor symptoms.

- Delusions and visual hallucinations are common.

- Functional impairments may initially be more

pronounced than cognitive deficits.
❖ Vascular dementia

- Computed tomography or magnetic resonance

imaging usually shows multiple vascular lesions of
the cerebral cortex and subcortical structures
resulting from the decreased blood supply to the
brain.
❖ Frontotemporal lobar degeneration (originally
called Pick disease) (50 – 60 years old) death
occur 2-5 years

- is a degenerative brain disease that particularly affects

the frontal and temporal lobes and results in a clinical
picture similar to that of Alzheimer disease.

- Early signs include personality changes, loss of social

skills and inhibitions, emotional blunting, and language
abnormalities.
❖ Prion diseases - are caused by a prion (a type of protein)
that can trigger normal proteins in the brain to fold
abnormally.

❖ Creutzfeldt–Jakob disease - is the most common prion

disease affecting humans.

- It is a CNS disorder that typically develops in adults aged

40 to 60 years.

- It involves altered vision, loss of coordination or abnormal

movements, and dementia that usually progresses rapidly
(a few months).
 Creutzfeldt–Jakob disease

- The cause of the encephalopathy is an infectious

particle resistant to boiling, some disinfectants (e.g.,
formalin, alcohol), and ultraviolet radiation.

- Mad cow disease and kuru (seen largely in New

Guinea from eating infected brain tissue) are other
prion diseases.
❖ HIV infection ~ can lead to dementia and other
neurologic problems.

- these may result directly from invasion of nervous tissue

by HIV or from other acquired immunodeficiency
syndrome–related illnesses such as toxoplasmosis and
cytomegalovirus.

- Mild Sensory Impairment to gross memory

- cognitive deficits to severe muscle dysfunction

❖ Parkinson disease - is a slowly progressive
neurologic condition characterized by tremor,
rigidity, bradykinesia, and postural instability.

- It results from loss of neurons of the basal

ganglia.

- cognitive and motor slowing, impaired memory, and

impaired executive functioning.
❖ Huntington disease

- an inherited, dominant gene disease that primarily

involves cerebral atrophy, demyelination, and
enlargement of the brain ventricles.

- facial contortions, twisting, turning, and tongue movements.

- Personality changes are the initial psychosocial manifestations

followed by memory loss, decreased intellectual functioning,
and other signs of dementia.

- begins in the late 30s or early 40s and may last 10 to 20 years or
more before death.
❖ Traumatic brain injury

- can cause dementia as a direct pathophysiological

consequence of head trauma.

- Repeated head injury (e.g., from boxing or football) may

lead to progressive dementia.

- The degree and type of cognitive impairment and

behavioral disturbance depend on the location and extent
of the brain injury.
Related Disorders:

Long-term use of alcohol that results in

dementia is called Korsakoff syndrome or
dementia. It was previously known as an
amnestic disorder since amnesia and
confabulation are common.
Drugs Used to Treat Dementia
NURSING INTERVENTIONS (Dementia)
NURSING INTERVENTIONS (Dementia)
NURSING INTERVENTIONS (Dementia)