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.
Delirium
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)
• 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
• 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 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
• 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:
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
Application of the Nursing Process:
Delirium (cont’d)
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)
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
Application of the Nursing Process:
Delirium (cont’d)
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
Application of the Nursing Process:
Delirium (cont’d)
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)
Application of the Nursing Process:
Delirium (cont’d)
Intervention
• Promoting safety
• Managing confusion
• Promoting sleep and nutrition
Application of the Nursing Process:
Delirium (cont’d)
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: 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
Dementia
• 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 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-Jakob disease
• Dementia due to HIV
• Parkinson’s disease
• Huntington’s disease
• Dementia due to head trauma
Cultural 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 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, which vary among clients
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
Application of the Nursing Process:
Dementia (cont’d)
Assessment (cont’d)
• 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
Application of the Nursing Process:
Dementia (cont’d)
Assessment (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
Application of the Nursing Process:
Dementia (cont’d)
Assessment (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:
• Risk for Injury • Impaired Environmental
Interpretation Syndrome
• Disturbed Sleep Pattern
• Impaired Memory
• Risk for Deficient Fluid
Volume • Impaired Socialization
• Risk for Imbalanced • Impaired Verbal
Nutrition Communication
• Chronic Confusion • Ineffective Role
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
Application of the Nursing Process:
Dementia (cont’d)
Intervention
• Promoting safety
• Promoting adequate sleep, nutrition,
hygiene, and activity
• Structuring the environment and
routine
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
Application of the Nursing Process:
Dementia (cont’d)
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: 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 Promotion

• Research continues to identify risk

factors for dementia (elevated levels of
plasma homocysteine)
• Regular participation in brain-
stimulating activities
Role of the Caregiver
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
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
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 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