COGNITIVE

DISORDERS
Prepared by:
Mary Ruth V. Enriquez, RN
MAN

Cognitive
Is the brains ability to process,
retain, and use information.
Cognitive abilities : include
reasoning, judgment, perception,
attention, comprehension, and
memory.
These are essential for many
important tasks, including making
decisions, solving problems,
interpreting the environment, and
learning new information.

Cognitive disorder
Is a disruption or impairment in these
higher-level functions of the brain.
Can have devastating effects on the
ability to function in daily life.
They can cause people to forget
the names of immediate family
members, to be unable to perform
daily household tasks, and to neglect
personal hygiene.

 The Primary Categories of

Cognitive Disorders are:
Delirium
Dementia
Amnestic disorders

AMNESTETIC DISORDER
Characterized by a disturbance
in memory that results directly
from the physiologic effects of a
general medical condition or
from the persisting effects of a
substance such as alcohol or
other drugs.

Delirium
is an acute condition; it develops
quickly, often in response to
prescription medications,
alcohol, exposure to some toxic
environmental substance, fever,
or systemic illness.
People in a state of delirium may
feel frightened, anxious, and
confused, and they may also
experience hallucination.

 Usually develops over a short

period , sometimes a matter of
hours, and fluctuates, or changes,
throughout the course of the day.
Client s w/ delirium have difficulty
paying attention, are easily
distracted and disoriented, and
may have sensory disturbances
such as illusion,
misinterpretations, or
hallucinations.

 Ex. Illusion: an electrical cord on

the floor may appear to them to
be a snake
Misinterpretation : they may
mistake the banging of a laundry
cart in the hallway for a gunshot.
Hallucination : they may see
angels hovering above when
nothing is there.

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

DSM-IV-TR DIAGNOSTIC CRITERIA

SYMPTOMS OF DELIRIUM

Difficulty with attention

Easily distractible
Disoriented
May have sensory disturbances such as
illusion, misinterpretation, or hallucinations
Can have sleep-wake cycle disturbances
Changes in psychomotor activity
May experience anxiety, fear, irritability,
euphoria, or apathy

Most common causes of

delirium
Physiologic or Metabolic
Hypoxemia
Electrolyte disturbances
Renal or hepatic failure
Hypoglycemia or hyperglycemia
Dehydration
Sleep deprivation
Thyroid or glucocorticoid disturbances
Thiamine or vit. B12 deficiency, vit C, niacin or protein
deficiency
Cardiovascular shock, brain tumor
Head injury, and exposure to gasoline
Pain solvents, insecticides and related substances

Infections :
Systemic sepsis
UTI
Pneumonia
Cerebral meningitis
Encephalitis
HIV
Syphilis

Drug related:
Intoxication
Anticholinergic
Lithium
Alcohol
Sedative and hypnotics
Reactions to anesthesia
Prescription medication, or illicit (street) drugs.

Treatment and
Prognosis
The primary treatment for
delirium is to identify and treat
any causal or contributing
medical conditions.
Some causes such as head injury
or encephalitis may leave clients
w/ cognitive, behavioral, or
emotional impairments even
after the underlying cause
resolves.

Pharmacology
Antipsychotic medication such as
haloperidol (Haldol) may be used in
doses of 0.5 to 1mg to decrease
agitation.
Sedative and benzodiazepines
are avoided because they may
worsen delirium.
The exception is delirium induced
by alcohol withdrawal, w/c
usually is treated w/

Nursing Interventions for

Delirium
1.Promoting clients safety
Teach client to request assistance for activities (getting out
of bed, going to bathroom)
Provide close supervision to ensure safety during activities.
Promptly respond to clients call for assistance
2. Managing clients confusion
Speak to client in a calm manner in a clear low voice; use
simple sentences.
Allow adequate time for client to comprehend and respond.
Allow client to make decisions as much as able.
Provide orienting verbal cues when talking with client.
Use supportive touch if appropriate.

3.Controlling environment to
reduce sensory overload.
Keep environmental noise to minimum
(TV, radio).
Monitor clients response to visitors;
explain to family and friends that
client may need to visit quietly one on
one.
Validate clients anxiety and fears, but
do not reinforce mispercepceptions.

4.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
client does not make requests.
Discourage daytime napping to help sleep
at night.
Encourage some exercise during day like
sitting in a chair, walking in hall, or other
activities client can manage.

DEMENTIA
Is a chronic, progressive deterioration
of the brain usually characterized by
severe memory loss, disorientation,
and impairments associated w/
attention, judgment, and inability to
take in and use new information.
Is a mental disorder that involves
multiple cognitive deficits, primarily
memory impairment, and at least one
of the following cognitive
disturbances

 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
Disturbances in executive
functioning : which is the ability to
think abstractly and to plan, initiate,

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.
Ex. 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 w/ the inability

to name familiar objects or people and
then progresses to speech that
becomes vague or empty w/ 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 chairs 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.

Onset and Clinical Course

When an underlying, treatable cause is not
present, the course of dementia is usually
progressive. Dementia often is described in
stages:
Mild : forgetfulness is the hallmark of
beginning, mild dementia. It exceeds the
normal, occasional forgetfulness experienced
as part of the aging process.
The person has difficulty finding words,
frequently loses objects, and begins to
experience anxiety about these losses.
Occupational and social settings are less
enjoyable , and the person may avoid this
stage.

 Moderate : confusion is apparent, along with

progressive memory loss. The person no
longer can perform complex tasks but
remains oriented to person and place.
He or she still recognizes familiar people.
Towards the 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.
The person may remain in the community if
adequate caregiver support is available, but
some people move to supervised living
situations.

 Severe : personality and

emotional changes occur. The
person may be delusional,
wander at night, forget the
names of his or her spouse and
children, requires assistance in
activities of daily living (ADLs).
Most people live in nursing
facilities when they reach this
stage unless extraordinary
community support is available.

The most common types of

dementia

Alzheimers disease
Vascular dementia
Picks disease
Creutzfeldt-Jacob disease
HIV infection
Parkinsons disease
Huntingtons disease

Alzheimers disease
Is a progressive brain disorder that
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.
It is evidenced by atrophy of cerebral
neurons, senile plaque deposits, and
enlargement of the third and fourth
ventricles of the brain.

Alzheimers disease

Alzheimers disease
Risk for Alzheimer's disease
increases w/ age, and average
duration from onset of
symptoms to death is 8 to 10
years.
Dementia of the Alzheimers
type, especially with late onset
(after 65 years of age), may have
a genetic component.

Vascular dementia
Has symptoms similar to those of
Alzheimers disease, but onset is typically
abrupt, followed by rapid changes in
functioning; a plateau, or leaving off
period; more abrupt changes; another
leveling-off period; and so on.
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.

Picks disease
Is a degenerative brain disease that
particularly affects the frontal and
temporal lobes and results in a clinical
picture similar to that of Alzheimers
disease.
Early signs include personality
changes, loss of social skills and
inhibitions, emotional blunting, and
language abnormalities.
Onset is most commonly 50 to 60 years
of age; death occurs in 2 to 5 years.

Creutzfeldt-Jacob disease
Is a central nervous system disorder that
typically develops in adults 40 to 60 years of
age.
It involves altered vision, loss of coordination
or abnormal movements, and dementia that
usually progresses rapidly (a few months).
The cause of the encephalopathy is an
infectious particle resistant to boiling, some
disinfectants (e.g., formalin, alcohol), and
ultraviolet radiation.
Pressured autoclaving or bleach can
inactivate the particle.

HIV INFECTION
Can lead to dementia and other neurologic
problem; these may result directly from
invasion of nervous tissue by HIV or from
other acquired immunodeficiency
syndrome-related illnesses such as
toxoplasmosis and cytomegalovirus.
This type of dementia can result in a wide
variety of symptoms ranging from mild
sensory impairment to gross memory and
cognitive deficits to severe muscle
dysfunction.

Parkinsons 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.
Dementia has been reported in
approximately 20% to 60% of people with
Parkinson's disease and is characterized
by cognitive and motor slowing, impaired
memory, and impaired executive
functioning.

Huntingtons disease
Is an inherited, dominant gene disease that
primarily involves cerebral atrophy,
demyelination, and enlargement of the brain
ventricles, initially, there are choreiform
movements that are continuous during waking
hours and involve 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.
The disease begins in the late thirties or early
forties and may last 10 to 20 years or more
before death.

Treatment and Prognosis

The underlying cause of dementia is
identified so that treatment can be
instituted.
For example, the progress of vascular
dementia, second most common type,
may be halted w/ appropriate treatment
of the underlying vascular condition (e.g.
Changes in diet, exercise, control of
hypertension or diabetes). Improvement of
cerebral blood flow may arrest the progress of
vascular dementia in some people.

 The prognosis for the progressive types

of dementia may vary, but all
prognoses involve progressive
deterioration of physical and mental
abilities until death. Typically , in the
later stages, client s have minimal
cognitive and motor function, are totally
dependent on caregivers, and are
unaware of their surroundings or people
in the environment. They may be totally
uncommunicative or make unintelligible
sounds or attempts to verbalize.

 For degenerative dementias, no

direct therapies have been found to
reverse or retard the fundamental
pathophysiologic processes. Levels
of numerous neurotransmitters
such as acetylcholine, dopamine,
norepinephrine, and serotonin
are decreased in dementia. This
has led to attempts at replishment
therapy with acetylcholine
precursors, cholinergic agonists,
and cholinesterase inhibitors.

Medications
Cholinesterase inhibitors : have
shown modest therapeutic effects
and temporarily slow the progress of
dementia.
Tacrine (Cognex)
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Reminyl)

 Clients w/ dementia demonstrate a

broad range of behaviors that can be
treated symptomatically. Doses of
medications are one half to two thirds
lower than usually prescribed.
Antidepressants are effective for significant
depressive symptoms.
Antipsychotics such as haloperidol (Haldol),
Olanzapine (Zyprexa), Risperidone
(Risperdal), and Quetiapine (Seroquel)
May be used to manage psychotic symptoms
of delusion, hallucinations, or paranoia.

 Lithium carbonate ,
Carbamazepine (Tegretol), and
Valproic acid (Depakote)
Help stabilize affective lability
and diminish aggressive
outbursts.
Benzodiazepines : used cautiously
because they may cause delirium
and can worsen already
compromised cognitive abilities.

Nursing Interventions for

Dementia
1. Promoting clients safety and protecting from injury
offer unobtrusive assistance w/ supervision of
cooking, bathing, or self-care activities.
. environmental triggers to help client avoid them.
2. Promoting adequate sleep, proper nutrition and
hygiene, and activity
.Prepare desirable foods and foods client can selffeed; sit w/ client while eating
.Monitor bowel elimination patterns, intervene w/
fluids and fiber or prompts
.Remind client to urinate; provide pads or diapers as
needed, checking and changing them frequently to
avoid infection, skin irritation, unpleasant odors.
.Encourage mild physical activity such as walking.

3. Structuring environment and

routine
Encourage client to follow regular routine
and habits of bathing and dressing
rather than impose new ones.
Monitor
amount
of
environmental
stimulation, and adjust when needed
4. Providing emotional support
Be
kind,
respectful,
calm,
and
reassuring, pay attention to client.
Use supportive touch when appropriate

5. Promoting interaction and

involvement
Plan activities geared to clients
interests and abilities
Reminisce with client about the past
If client is nonverbal, remain alert to
nonverbal behavior,
Employ techniques of distraction,
time away, going along or reframing
to calm clients who are agitated,
suspicious, or confused.

Comparison of Delirium and

Dementia
INDICATOR

DELIRIUM

DEMENTIA

ONSET

RAPID

GRADUAL AND
INSIDUOUS (slowly and
harmful)

DURATION

BRIEF (HOURS TO DAYS)

PROGRESSIVE
DETERIORATION

LEVEL OF
CONSCIOUSN
ESS

IMPAIRED, FLUCTUATES

NOT AFFECTED

MEMORY

SHORT-TERM MEMORY
IMPAIRED

SHORT-TERM MEMORY
IMPAIRED, EVENTUALLY
DESTROYED

INDICATOR

DELIRIUM

DEMENTIA

SPEECH

MAY BE SLURRED,
RAMBLING,
PRESSURED,
IRRELEVANT

NORMAL IN EARLY
STAGE, PROGRESSIVE
APHASIA IN LATER
STAGE.

THOUGH PROCESSES

TEMPORARILY
DISORGANIZED

IMPAIRED THINKING,
EVENTUAL LOSS OF
THINKING ABILITIES

PERCEPTION

VISUAL OR TACTILE
HALLUCINATIONS,
DELUSION

OFTEN ABSENT, BUT

CAN HAVE PARANOIA,
HALLUCINATIONS,
ILLUSIONS

MOOD

ANXIOUS, FEARFUL IF
HALLUCINATING;
WEEPING, IRRITABLE

DEPRESSED AND
ANXIUOS IN EARLY
STAGE, LABILE MOOD,
RESTLESS PACING,
ANGRY OUTBURSTS
IN LATER STAGE