Cognitive Disorders

Dementia
Delirium
Dementia of the Alzheimer’s Type
Amnestic Disorders
Cognitive Disorders
 Cognition refers to the mental processes of
comprehension, judgment, memory, and reasoning
in contrast to emotional and volitional (willfull or
free-will) processes (Edgerton & Campbell, 1994).
 A cognitive disorder occurs when there is a
clinically significant deficit in cognition from a
previous level of functioning.
 At least 70 known cognitive disorders are due to
intracranial or primary diseases of the central
nervous system (eg, epilepsy, brain trauma, or
infection) and extracranial diseases or diseases of
other organ systems (eg, drug intoxication,
poisons, or systemic infections).
Cognitive Function
 Research has been done to determine the
effects of aging on the brain and cognitive
function. Some findings include the
following:
 The normal human brain weighs approximately
1350 grams and declines approximately 7% to
8% in weight as one ages.
 Ventricular size increases with age.
 Cell loss is not uniform because the frontal lobes
degenerate at a faster rate than the other lobes.
 Gray matter is lost at a
greater rate initially, but
white matter loss
disproportionately
increases as one ages.
 Approximately 50% of
aging individuals
experience
atherosclerosis in
cerebral vessels.
 Changes in
neurotransmitter
function occur, such as
alterations in
neurotransmitter
concentration, receptor
density, and functional
activity (Salloway,
1999).
Behavior Due to Central Nervous System
Pathology
 Frontal lobe:
 Lack of attention tenacity or persistence
 Loss of emotional control, rage, violent behavior
 Changes in mood and personality, uncharacteristic behavior
 Expressive aphasia or dysphasia
 Parietal lobe:
 Neglect or inattention to left half of space, resulting in possible
self-injury or unintentional contact with others that could be
viewed as aggressive behavior
 Temporal lobe:
 Inability to store or retrieve information
 Inability to comprehend speech due to loss of hearing or
receptive aphasia
 Occipital lobe:
 Visual disturbances such as agnosia or the inability to
recognize by sight
 Limbic lobe:
• Inability to feed self
• Inability to learn or store information
 Decrease in socialization
 Lack of emotional expression or apathy
Delirium
 Delirium is defined as a transient cognitive disorder, usually
acute or subacute in onset, presenting as a reversible global
dysfunction in cerebral metabolism.
 usually due to disturbance of brain pathology by a medical
disorder or an ingested substance.
 Delirium is considered a syndrome (eg, a group of signs and
symptoms that cluster together), not a disease, that has
many causes.
Three major causes are:
1. central nervous system diseases (eg, epilepsy, meningitis, or
encephalitis),
2. systemic illnesses (eg, heart failure or pulmonary
insufficiency), and
3. either drug intoxication or withdrawal from pharmacologic or
toxic agents.
 Other causes of delirium include endocrine or
metabolic disorders (eg, hypoadrenocorticism
or hypercalcemia) and deficiency diseases (eg,
thiamine, nicotinic acid, or folic acid). In
addition, systemic infections, electrolyte
imbalance, postoperative states, and traumatic
injury to the head or body also are associated
with causing delirium
Dementia
 Dementia refers to a syndrome of global or diffuse brain
dysfunction characterized by a gradual, progressive, chronic
deterioration of intellectual function.
 persistent and stable nature of the impairment distinguishes it from
the altered levels of consciousness and fluctuating deficits of
delirium.
 the majority of cases (up to 75%) are of two main types: dementia
of the Alzheimer's type and vascular dementia.
Etiology of Dementia of the Alzheimer's Type (DAT)
 Current theories regarding the causes of dementia are cited below
and include:
 The genetic theory proposing a genetic link to DAT focuses on three
genes on three separate chromosomes (1, 14, 21).
 The immune system theory suggesting that DAT is the result of
immune system malfunctions.
 The oxidation theory stating that the buildup of damage from
oxidative processes in neurons results in the loss of various body
functions.
 The virus and bacteria theory proposing that DAT
may be due to a viral- or bacterial-induced condition
secondary to the breakdown of the immune system
(eg, herpesvirus).
 The nutritional theory postulating that poor nutrition
and lack of mental stimulation during childhood may
predispose one to DAT later in life.
 The metal deposit theory speculating that an
accumulation of aluminum ions replacing iron ions
may contribute to existing dementia.
 The neurotransmitter theory hypothesizing that DAT
is due to a decrease in acetylcholine, dopamine,
norepinephrine, or serotonin levels, limiting neuronal
activity. A second theory postulates that excessive
stimulation of glutamate damages neurons.
FIGURE 24.3 Positron emission tomography scan comparing a
control client subject and a client with dementia of the
Alzheimer's type.
 Etiology of Diseases Associated With Dementia
 Several diseases are often associated with dementia (APA, 2000;
Busse & Blazer, 1996; Sadock & Sadock, 2003). They include:
 Familial multiple system taupathy (eg, a buildup of tau protein in
the neurons and glial cells) occurring in individuals in their forties
or fifties; thought to be carried on chromosome 17 and shares
some brain abnormalities with DAT; often referred to as presenile
dementia.
 Lewy body disease resulting from neurohistologic changes in the
brain stem and widespread throughout the cerebral cortex;
clinically similar to DAT, presenting with some features of
Parkinson's disease.
 Pick's disease, progressive disorder of middle and late life
characterized by atrophy and microscopic changes of the
frontotemporal regions; difficult to differentiate from DAT.
 Parkinson's disease due to the presence of neurohistologic lesions
in the basal ganglia; associated impairment of cognitive abilities;
commonly associated with dementia.
 TABLE 24.1 Comparison of Dementia, Delirium, and Depression
SYMPTOMS DEMENTIA DELIRIUM DEPRESSION

Judgment Impaired May be impaired May seem impaired

Mood Fluctuates, Apathetic Fluctuates Labile, Apathetic

Memory Impaired Impaired May seem impaired;

selective

Cognition Disordered reasoning Disordered reasoning “I don't know” responses

Orientation Disoriented Disoriented “It doesn't matter”

responses

Thoughts Confused Confused Low self-concept

Suspicious Suspicious Negativistic, hopelessness
Paranoid Incoherent Death related
Possible delusions

Perception No change Misinterpretations Auditory hallucinations

Visual hallucinations
Consciousness Normal Clouded Normal

Speech Sparse Sparse or fluent Fluent or retarded

Repetitive Incoherent (slow response)
Soft-spoken, selectively
mute
Behavior Agitation Agitation Insomnia or sleeps
Wanders May wander often
Insomnia Insomnia Changes in appetite
Complains of fatigue
Mental status Poor testing Poor testing Inconsistently poor
Progressively worsens Improves when performance
Inappropriate answers medically stable “I don't know”
Improves with answers
treatment
Activities of daily Deteriorate as Usually remain stable May deteriorate with
living dementia progresses unless medically major depression due
unstable to apathy
PROGNOSIS No return to premorbid Return to premorbid Risk of injury or
function, chronic, function if cause is suicide.
depends on cause as is correctable and is Return to premorbid
generally insidious in corrected in time. function on recovery
onset Generally acute onset Usually requires
treatment
Coincides with major
life changes
Amnestic Disorders
 Amnestic disorders are described as the acquired impaired
ability to learn and recall new information or to recall
previously learned information.
 The etiology of an amnestic disorder is usually damage to
diencephalic and medial temporal lobe structures, important
in memory functions (Peskind & Raskind, 1996).
Causes of amnestic disorders may be:
1. Medical conditions such as thiamine deficiency
and hypoglycemia;
2. Primary brain conditions such as head trauma;
and
3. Substance-related disorders such as those
involving alcohol and neurotoxins .
 Classification of Amnestic
Disorders

 Retrograde Amnesia
 A type of amnesia wherein memories
that were encoded or in the process of
being encoded in long term memory are
erased.
 Anterograde Amnesia
 A type of amnesia wherein there is
difficulty creating recent term lost of
memories.
 Dissociative Amnesia
 The client cannot remember important
personal information usually of a traumatic
or stressful nature.
 Korsakoff Syndrome
 Alcohol-induced amnestic disorder which
results from a chronic thiamine or vitamin B
deficiency.
 Clinical Symptoms and Diagnostic Characteristics of
Cognitive Disorders

 Delirium
- is one of the most common and, by far, one of the most life-
threatening psychiatric illnesses.
Clinical symptoms includes:
- a rapid onset with symptoms varying sharply in a short
period.
- Disorientation to person and place usually occurs.
- Dysnomia, the inability to name objects, and
- dysgraphia, the impaired ability to write, may occur.
- Thought processes appear confused, with possible delusional
content.
- Asterixis, an abnormal movement in which the client exhibits
a peculiar flapping movement of hyperextended hands,
 Dementia
 Dementia is characterized by impaired judgment, orientation,
memory, cognition, and attention, which are affected either by a
pattern of simple, gradual deterioration or by rapid, complicated
deterioration.
 Clients with dementia often seem to exhibit increased confusion,
restlessness, agitation, wandering, or combative behavior in the late
afternoon and evening hours.

The DSM-IV-TR lists 12 subtypes of dementia:

 Dementia of the Alzheimer's type
 Vascular dementia
 Dementia due to human immunodeficiency virus (HIV) disease
 Dementia due to head trauma
 Dementia due to Parkinson's disease
 Dementia due to Huntington's disease
 Dementia due to Pick's disease
 Dementia due to Creutzfeldt-Jakob disease
 Dementia due to other general medical conditions
  Dementia due to other general medical conditions
 Substance-induced persisting dementia
 Dementia due to multiple etiologies
 Dementia, not otherwise specified

 Clinical symptoms
Dementia of the Alzheimer's Type (DAT)
 silent epidemic characterized by the development of multiple
cognitive deficits including memory impairment,
 aphasia (language disturbance),
 apraxia (impaired ability to carry out motor activities despite
motor function),
 agnosia (failure to recognize or identify objects despite intact
sensory function), and disturbances in executive functioning (eg,
planning, organizing).
 The course is characterized by gradual onset. The client is aware
of the loss of mental abilities as they occur.
  diagnosis is coded or labeled based on when and what symptoms
appear.
 If clinical symptoms appear before age 65 years, the diagnosis is
coded as DAT with early onset; after age 65, the coding with late
onset is used. Additional coding indicates with delirium, with
delusions, with depressed mood, or uncomplicated.
 Stages of Dementia of the Alzheimer's Type
 first system groups clinical symptoms into three progressive stages
described as mild, moderate, and severe in nature.
 second system describes seven stages of AD according to functional
consequences
Vascular Dementia
 Vascular dementia, formerly known as multi-infarct dementia, is the
second most common cause of dementia after DAT. The disorder is
more common in males than in females. The onset of vascular
dementia is usually earlier than that of DAT. Onset is generally
abrupt with fluctuating, rapid changes in memory and other
cognitive impairment.
  Apathy, unsteady gait, weakness, dizziness, and sensory loss
generally occur.
 Clients with vascular dementia often exhibit the same clinical
symptoms seen in DAT: aphasia, apraxia, agnosia, and
disturbances in executive functioning.
Dementia Due to Other General Medical Conditions
 This classification is used to diagnose dementia due to general
medical conditions (eg, HIV, traumatic brain injury, and
Parkinson's disease); endocrine, nutritional, and infectious
conditions; structural lesions of the brain; and renal or hepatic
dysfunction.
Amnestic Disorders
 Individuals with amnesia experience impairment in their ability
to recall information or past events. Clients with anterograde
amnesia are unable to recall events of long ago but have
normal recall of recent events. Retrograde amnesia refers to
the loss of memory of events occurring before a particular time
in a person's life.
The Nursing Process
Assessment
 The single most important piece of information when assessing a client
with cognitive impairment is a careful history from the client's family or
another reliable observer.
 Assessment focuses on the client's ability to meet basic needs,
appearance, severity and duration of cognitive impairment, and
behavioral manifestations, including any associated clinical symptoms to
determine the presence of delirium, dementia, or amnestic disorder.
 Judgment, orientation, memory, affect, and cognition (JOMAC) are key
areas to assess. Also note the client's intellectual ability, both past and
present.

Comprehensive Assessment of Impaired Cognition and Behavioral

Manifestations
 History
 Will likely require interview with close family or friend
 Data regarding birth, developmental stages, medical history, medication,
time of onset of clinical symptoms, rate of progression, and any family
history of dementia
 Physical Examination
 Mental status evaluation: Obtain information regarding any past
psychiatric treatments.
 General physical and neurologic examination including pain
assessment (client may not be able to self-report pain).
 Observe for behaviors associated with pain such as crying or
moaning, rubbing or guarding, frowning or grimacing.
 Nursing Diagnoses
 Early diagnosis of a cognitive disorder such as dementia is
important. Early diagnosis provides time for decision-making.
 Examples of NANDA Nursing Diagnoses: Cognitive Disorders
 Interrupted Family Processes related to shift in family roles
 Inefffective Role Performance related to loss of previous
capabilities
 Disturbed Thought Processes related to hallucinations and
delusions
 Hopelessness related to progressive nature of Alzheimer's disease
  Impaired Social Interaction related to attention deficits
 Ineffective Coping related to memory deficits
 Risk for Injury related to impulsive behavior
 Risk for Injury related to poor judgment
 Situational Low Self-Esteem related to loss of previous capabilities
 Social Isolation related to irritability
 Social Isolation related to bizarre behavior
 EXAMPLES OF STATED OUTCOMES: COGNITIVE DISORDERS
 The client will verbalize decreased frequency of delusions and
hallucinations.
 The client will demonstrate decreased agitation.
 The client will be free of injury.
 The client will not harm others or destroy property.
 The client will verbalize feelings of powerlessness or hopelessness.
 The client will develop alternate communication skills.
 The client will verbalize increased feelings of self-worth.
 Implementation
 Working with clients with cognitive impairment frequently results in
health care personnel being confronted with their own human
limitations
 Emotional reactions are possible when faced with the inability to
control inevitable deterioration in some clients.

1. Establishment of a Safe Environment

 A calm, direct, supportive approach with a predictable schedule is necessary
when providing care for clients who are forgetful, disoriented, confused, or
frightened, or who exhibit alterations in perception.
2. Assistance in Meeting Basic Needs
 If a comorbid medical condition exists, be sure to provide routine care such
as monitoring vital signs, assessing level of consciousness, and meeting
physiologic needs. In addition, assist with ADLs as necessary.
3. Stabilization of Behavior
 Approximately 90% of clients with dementia may exhibit measurable
behavioral disturbances, and one half to one third of all clients with the
diagnosis of cognitive disorder are overtly aggressive
 Medication Management
 Medication is frequently required to treat medical
conditions that contribute to cognitive disorders.
 Atypical antipsychotics, benzodiazepines, and
antidepressants are frequently used.
 Medicating clients may prove to be challenging due
to several factors. Clients may:
 Be unable to comprehend the need for a medication
 Be unable to identify self due to impaired cognition and
communication
 Resist taking medication due to impaired thoughts such as
delusions or paranoid thoughts
  Exhibit fluctuations in cognition, mood, and behavior
 Exhibit behavioral manifestations similar to adverse
effects of prescribed medication
 Recent advances in the treatment of dementia,
specifically DAT, have resulted in several alternative
 Client and Family Education
 The diagnosis of a cognitive disorder can have
devastating consequences for clients and their families.
After a client has been diagnosed, be sure that the client
and family are informed about the disease and the
progression of clinical symptoms.
THE END