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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.

Cognitive Disorders
Delirium General medical Substance-related Multifactorial substance induced not known Dementia Amnestic Alzheimer's type General medical Vascular origin Substance-related HIV-related Head trauma-related Parkinson's-related Huntington's-related Pick's-related Creutzfeldt -Jakobrelated General medical origin Substance-related Multifactorial

Delirium

Delirium: disturbance of consciousness a change in cognition Perceptual disturbance
• Acute and fluctuating • Difficulty paying attention, distractibility, and disorientation • Memory - often impaired • Sensory disturbances include illusions, misinterpretations, hallucinations • Disturbances in sleep/wake cycle, anxiety, fear, irritability, euphoria, apathy

Delirium (cont’d)

• Risk factors: hospitalization for general medical conditions, older acutely ill clients, severe physical illness, older age, and baseline cognitive impairment • Etiology: identifiable physiologic, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal

Treatment and Prognosis
• Treatment of the underlying medical condition • 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
• If quiet and resting, no medication • psychomotor agitation- sedation with an antipsychotic/ anti anxiety may prevent inadvertent self-injury • alcohol withdrawal - benzodiazepines • Adequate food and fluid (calories,CHON, vits, thiamine) • Physical restraints only when necessary • Orient to person, place and time

Data Analysis Nursing diagnoses may include:
• • • • • • •

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

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:

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

• 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

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

Dementia
• Dementia involves multiple cognitive deficits, primarily memory impairment
– – – – –
– – – –

J - Judgement A - affect M - memory C - confusion O -orientation
Aphasia Apraxia Agnosia Disturbance in executive functioning

• and at least one of the following:

• Dementia is progressive

Classification
1. Primary – not reversible, progressive
1. Alzheimer’s, Multi infarct, Pick’s Disease

2. Secondary – as a result of pathological process.

Onset 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)

Etiology
• Alzheimer’s disease • Vascular dementia (may have sudden onset; progression may be arrested with treatment) • Pick’s disease • Creutzfeldt-Jacob disease • Dementia due to HIV • Parkinson’s disease • Huntington’s disease • Dementia due to head trauma

Treatment 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)
• 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.

Application of the Nursing Process: Dementia Assessment
• 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

Assessment:

Application of the Nursing Process: Dementia

• 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)

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

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

Assessment (cont’d)
• 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

Assessment (cont’d)

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

• 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

Assessment (cont’d)

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

• 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

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

Nursing diagnoses include: • Impaired Environmental Risk for Injury Interpretation Syndrome Disturbed Sleep Pattern • Impaired Memory Risk for Deficient Fluid • Impaired Socialization Volume • Impaired Verbal Risk for Imbalanced Communication Nutrition • Ineffective Role Chronic Confusion Performance

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

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

Application of the Nursing Process: Dementia (cont’d) Intervention (cont’d)
• Providing emotional support
– Supportive touch – – – –

• Promoting interaction and involvement
Reminiscence therapy Distraction Time away Going along

Mental Health Promotion

• Research continues to identify risk factors for dementia (elevated levels of plasma homocysteine) • Regular participation in brainstimulating activities

Related 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)

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

Self-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

Geriatic Considerations
1. Do not push too fast in getting information, assist in ADL, insisting to socialize. 2. 3 R’s – routine, reinforment, repetition, (relaxation). 3. Avoid dependency 4. Do not isolate 5. Protect from injury 6. communicate – simple, clear and concise. Face to face, use visual cues 7. Orient frequently 8. 3 P’s – protecting dignity, preserving functioning, promoting quality of life.