COGNITIVE DISORDERS Eric F. Pazziuagan, RN, MAN
COGNITION The brain’s ability to process, retain, and use information. Include: reasoning, judgment, perc eption, attention, compreh ension, and memory.
COGNITIVE DISORDER Is a disruption or impairment in the higher- level functions of the brain. Devastating effects on the ability to function in daily life. Can cause people to forget the names of the family members, to be unable to perform daily tasks, and to neglect personal hygiene.
DELIRIUM 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. Clients have difficulty paying attention, are easily distracted and disoriented, and may have sensory disturbances such as illusions, misinterpretations, or hallucinations.
10%- 15% people in the hospital with general medical conditions are delirious at any given time. 30%- 50% of acutely ill older adult clients at some time during their hospital stay. Risk factors: increased severity of physical illness, older age, and baseline cognitive impairment such as that seen in dementia. Children may be more susceptible (febrile and medications)
ETIOLOGY Physiologic disturbances Metabolic disturbances Cerebral disturbances Drug intoxication or withdrawal
SYMPTOMS Difficulty with attention Easily distractable Disoriented May have sensory disturbances such as illusions, misinterpretations, or hallucinations Can have sleep- wake cycle disturbances Changes in psychomotor activity May experience anxiety, fear, irritability, euphoria, or apathy
TREATMENT Primary treatment: identify and any causal or contributing medical conditions.
Psychopharmacology Need no specific medication aside from that indicated to the specific condition. Antipsychotics: Haloperidol (Haldol), 0.5- 1 mg. To decrease agitation. Adequate food and fluid intake IV fluids or TPN
NURSING MANAGEMENT Client’s safety is a priority. Meet their physiologic and psychologic needs. Behavior, mood, and level of consciousness of these clients can fluctuate rapidly throughout the day.
DEMENTIA A mental disorder that involves multiple cognitive deficits, primarily memory impairment, and at least one of the following disturbances: Aphasia: deterioration of language function. Apraxia: inability to execute motor functions despite intact memory abilities. Agnosia: 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. Cognitive deficits must be sufficiently severe to impair social or occupational functioning and must represent a decline from previous functioning. MEMORY IMPAIRMENT: the prominent early sign. Recent memory first before remote memory
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.” May exhibit: Echolalia: echoing what is heard 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: may be frustrating for clients. Disturbances in executive functioning: evident due to inability to learn new material, solve problems, or carry out daily activities.
DSM-IV-TR DIAGNOSTIC CRITERIA Loss of memory (initial stages, recent memory loss; later stages, remote memory loss). Deterioration of language function (forgetting names of common objects such as chair or table, palilalia, and echolalia) Loss of ability to think abstractly and to plan, initiate, sequence, monitor or stop complex behaviors (loss of executive function).
Onset and Clinical Course Mild: forgetfulness (hallmark of beginning, mild, dementia). It exceeds the normal, occasional forgetfulness as part of the aging process. Difficulty finding words, frequently loses objects, and feels anxious about these losses Occupational and social settings are less enjoyable, may avoid them
Moderate: confusion is apparent, along with progressive memory loss. Can no longer perform complex tasks but remains oriented to person and place. Still recognizes familiar people. Toward the end of the 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
Severe: personality and emotional changes. May be delusional, wander at night, forget the name of his spouse and children, and require assistance in ADLs. Usually lives in nursing facilities when they reach this stage.
Etiology Causes vary, although the clinical picture is similar for more dementias. Often, no definitive diagnosis can be made until completion of postmortem examination. Metabolic activity is decreased in the brain. Genetic component for some forms: Huntington Infections: HIV, Creutzfeldt-Jacob disease
Alzheimer’s disease Progressive brain disorder that has a gradual onset but causes an increasing decline of functioning, including loss of speech, loss of motor function, and profound personality and behavioral changes such as paranoia, delusions, hallucinations, inatten tion to hygiene, and belligerence. Evidenced by: atrophy of cerebral neurons, senile plaque deposits, and enlargement of the third and fourth
Risk increases with age; average duration from onset of symptoms to death is 8- 10 years. Dementia of Alzheimer’s type, especially with late onset (after 65 years of age), may have a genetic component. Shown links to chromosomes 21, 14, and 19.
Vascular dementia Symptoms similar to AD, but onset is typically abrupt, followed by rapid changes in functioning; a plateu, or levelling-off period; more abrupt changes; more abrupt changes; another levelling-off period; and so on. CT or MRI usually shows multiple vascular lesions of the cerebral cortex and subcortical structures resulting from the decreased blood supply to the brain.
Pick’s disease Degenerative brain disease that particularly affects the frontal and temporal lobes and results in a clinical picture similar to that of AD. Early signs: personality changes, loss of social skills and inhibitions, emotional blunting and language abnormalities. Onset: 50- 60 years old; death: 2-5 years
Creutzfeldt- Jakob Disease CNS disorder that typically develops in adults 40-60 years old. Involves altered vision, loss of coordination or abnormal movements, and dementia that usually progresses (a few months). Cause: infectious particle resistant to boiling, UV radiation, and some disinfectants.
HIV infection Can lead to dementia and other neurologic problems. May result directly from an invasion of nervous tissue by HIV or from other acquired immuno-deficiency illnesses such as taxoplasmosis and cytomegalovirus. May result in a wide variety of symptoms ranging from mild sensory impairment to gross memory and cognitive deficits to severe muscle dysfunction.
Parkinson’s disease Slowly, more progressive condition chracterized by tremor, rigidity, bradykinesia, and postural instability. Results from loss of neurons of the basal ganglia. 20%-60% has dementia
Huntington’s Disease An inherited, dominant gene disease that primarily involves cerebral atrophy, demyelination, and enlargement of brain ventricles. Initially, there are choreiform movements that are continuous during waking hours and involve facial contortions, twisting, and 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 40s and may last 10-20 years or more before death.
Head Trauma Dementia can be a direct pathophysiologic consequence. Degree and type of cognitive impairment and behavioral disturbance depend on the location and extent of the brain injury. When it occurs as a single injury, the dementia is usually stable rather than progressive. Repeated head injury may lead to progressive dementia.
Treatment and Prognosis Underlying cause is identified so that treatment can be instituted. Improvement of blood flow may arrest the progress of vascular dementia in some people. Degenerative dementias: no treatment have been found to reverse or retard the fundamental physiologic processes.
Assessment Mental Status Exam History: family, friends, or care givers General appearance and motor behavior: Aphasia: cannot name familiar objects or names Apraxia loss of ability to perform tasks Uninhibited behavior: inappropriate jokes, neglecting personal hygiene, showing undue familiarity with strangers, disregarding social conventions for acceptable behavior.
Mood and affect: Anxiety and fear: initial Labile mood Anger and hostility Aggression Wandering at night Agitation withdrawal Thought processes and Content: Initial: abstract thinking is impaired Delusions of persecution
Sensorium and Intellectual process Memory deficits Confabulation: make up answers to fill up gaps Agnosia Confusion Hallucination Judgement and insight Poor judgment Insight is limited
Self- concept Angry and frustrated: initially sadness Roles and relationships Work performance suffers Roles deteriorate Limits in relationship Psychologic and self-care considerations Disturbed sleep-wake cycles Incontinence Neglect bathing and grooming
Data Analysis Risk for injury Disturbed sleep pattern Risk for deficient fluid volume Risk for imbalance nutrition: less than body requirements Chronic confusion Impaired environmental interpretation syndrome Impaired memory Impaired social interaction Impaired verbal communication Impaired role performance
Nursing Interventions Promoting patient’s safety and protecting from injury. Offer unobtrusive assistance with or supervision of cooking, bathing, or self-care activities. Identify environmental triggers to help client avoid them.
Promoting adequate sleep, proper nutrition and hygiene and activity. Prepare desirable foods and foods client can self- feed; sit with client while eating. Monitor bowel elimination patterns; interfere with 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 activity such as walking.
Providing emotional support. Be kind, respectful, calm and reassuring; pay attention to client. Structuring environment and routine. Encourage clients to follow regular routine and habits of bathing and dressing rather than imposing on new ones. Monitor amount of environmental stimulation, and adjust when needed.
Promoting interaction and involvement Plan activities geared towards client’s interests and activities 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.