Neurocognitive Disorders

What is cognition?

System of interrelated abilities such as perception, reasoning, judgment, intuition, and memory

• Allows one to be aware of oneself

What is memory?

Facet of cognition, retaining and recalling past experiences

What is delirium?

Acute cognitive impairment with multiple causes

What is dementia?

Chronic cognitive impairment differentiated by cause, not symptom patterns – NOT NORMAL AGING

What to know about delirium?

• Clinical Course

  • Disturbance in consciousness and a change in cognition developing over a short period of time

  • Sudden onset, symptoms may fluctuate

  • Usually reversible if the underlying cause identified

  • Serious; should be treated as an emergency

    • Ongoing assessments should be completed to identify delirium EARLY!!

• Diagnostic criteria

  • A disturbance of consciousness (reduced awareness of the external environment) with reduced ability to focus, sustain, or shift attention.

  • A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting dementia.

  • Develops over a short period of time (usually hours to days) and tends to fluctuate over the course of a 24-hour period.

• Epidemiology

  • Prevalence rates range from 10% to 50% of older adults in acute care settings

    • Common in older postoperative patients

      • BUT…can occur AT any age

• Risk factors

  • Pre-existing cognitive impairment

  • Severe illness

  • Age

• Etiology in older adults

  • Medications – drug toxicity

  • Infections – sepsis, UTI

  • Fluid and electrolyte imbalance

  • Metabolic disturbances – hepatic or renal failure; hypoglycemia

  • Hypoxia and ischemia

• Predisposing factors

  • Advanced age

  • Brain damage or dementia

  • Sensory over- or underload

  • Immobilization

  • Sleep deprivation

  • Psychosocial stress

  • Severe medical illness

What is included in recovery-oriented care for persons with delirium?

• Teamwork and Collaboration

  • Elimination or correction of the underlying cause

  • Symptomatic and supportive measures – maintenance of fluid/electrolyte balance, rest)

• Safety Issues

  • Stop all suspected medications

  • Monitor changes in vital signs, behavior, and mental status – should be monitored closely (at least every 2 hours)

What is included in evidence-based nursing care for persons with delirium?

• Mental Health Nursing Assessment

  • Current and past mental health status – need our baseline!

• Physical examination and review of systems

  • Physical function

  • Vital signs, use of sensory aids, pain and sleep

  • Lab results may indicate hypoxia, hypoglycemia, and ST-segment elevation myocardial infarction

  • Assess for infections such as urinary tract infection, pneumonia, and sepsis

  • A neurological assessment to rule out TIA (transient ischemic attack), stroke, intracranial hemorrhage or mass).

• Pharmacologic assessment

  • Alcohol intake and smoking history

  • Meds can cause delirium – cold medicine w/a system that is unable to metabolize well = predisposition

• Psychosocial Assessment

  • Mental status: fluctuating level of consciousness and reduced awareness of environment  (shifting focus or attention)

  • Behavior

    • Restless or agitated = hyperactive delirium

    • Lethargic and slow to respond = hypoactive delirium

    • Both restless and slow response (switch back and forth) = mixed delirium

• Family Environment

  • Living arrangements

  • Social isolation

  • Family interaction

  • Support system

What is included in clinical judgment for delirium?

• Address life threatening issues

  • Respiratory

  • Cardiovascular

• Combative behavior

  • De-escalation is a priority

    • SAFETY! SAFETY! SAFETY!

What are the mental health nursing interventions?

• Interventions

  • Safe therapeutic environment

  • Maintenance of fluid and electrolyte balance

  • Adequate nutrition

  • Prevention of aspiration; skin breakdown

• Complementary and Non-pharmacological

  • Aromatherapy, massage, acupuncture, and therapeutic touch

• Medications

  • Underlying medical problem is treated

    • Antipsychotics, Benzodiazepines

• Continuum of Care

  • Treatment settings

• Psychosocial Interventions

  • Frequent interaction and support

  • Encouragement to express fears and discomforts

  • Environmental control, Adequate lighting; reasonable noise level, Easy-to-read calendars and clocks

  • Frequent verbal orientation, Eyeglasses and hearing aids readily available

• Psychoeducation

  • Safety

• Evaluation and Treatment Outcomes

  • Correction of the underlying physiologic alteration

  • Resolution of confusion

  • Family member verbalization of understanding of confusion

  • Prevention of injury

What to know about dementia?

• 55 million people are leaving with some form of dementia worldwide

• Alzheimer’s accounts for 60-80% of dementia cases

• 6.7 million people are living with Alzheimer’s Disease in the U.S.

• 1 in 9 adults 65<

• Higher incidence in those of Latino descent and African Americans

• 5^th leading cause of death in older adults

• 150,000 in Georgia

• 50% of those with Alzheimer’s have evidence of mixed dementias

What are the risk factors for Alzheimer’s disease?

• Non-modifiable

  • Age

  • Genetics-Familial Link

  • Trisomy 21

• Modifiable

  • Poor Cardiovascular Health

  • Poor Diet

  • Lack of exercise

  • Smoking

  • Lower education and SES

  • Poor social & Cognitive Engagement

  • Traumatic Brain Injury

• Less evidence, but under investigation

  • Poor Sleep

  • Exposure to high levels of air pollution

  • Critical Illness and hospitalization

What to know about Alzheimer’s Disease?

• Clinical Course

  • Degenerative, progressive neuropsychiatric disorder

    • Cognitive impairment

    • Emotional and behavioral changes

    • Physical and functional decline

    • Ultimately, death

  • Types

    • Early onset (65 years and younger): rapid progression

    • Late onset (older than 65 years): more common

• Diagnostic Criteria

  • Multiple cognitive deficits

  • One or more of the following:

    • Aphasia: alterations in language

    • Apraxia: impaired ability to execute movement

    • Agnosia: failure to recognize or identify objects

    • Disturbance of executive functioning

• Etiology

  • Amyloid Precursor Protein (APP)

  • Beta-amyloid plaques – aphasia and visuospatial issues

  • Neurofibrillary tangles

  • Synaptic Micron RNA and Neurotransmission

  • Genetic factors

  • Oxidative stress, free radicals, and mitochondrial dysfunction

  • Inflammation

  • Gut-Brain Axis Alteration

What is pre-clinical disease?

• No symptoms

• Diagnostic Evidence of disease

  • Increase amyloid plaque via PET scan

  • Increased TAU proteins in CSF

  • Decreased metabolism of glucose via PET scan

What to know about mild cognitive impairment?

• Subtle symptoms that may only be recognizable by those close to the patient

• Forgetting appointments etc

• Difficulty making decisions

• Difficulty remembering steps in a task or misjudging the time needed to complete a task

• Visual Perception changes

What to know about mild Alzheimer’s?

• Coming up with the right word or name.

• Remembering names when introduced to new people.

• Having difficulty performing tasks in social or work settings.

• Forgetting material that was just read.

• Losing or misplacing a valuable object.

• Experiencing increased trouble with planning or organizing

What is included in the patient teaching about early Alzheimer’s?

• Develop Daily routines

• Do only one task at a time

• Memory aides such as calendars, alarms, notes, list

• Develop strategies for individual task you are having issues remembering (taking medication, etc)

• Ask for help with task that have become too difficult and focus on the things you can do

• Get support-family, friends, church, prayer, support groups

• Get plenty of exercise

• Eat a healthy diet

• Stay up to date on physicals and other conditions

• Mental stimulation exercises

• Minimal alcohol intake

• Share your feelings with someone you can trust

• Minimize stress

  • Identify sources of stress and triggers

  • Change your environment

What are the nursing interventions for early Alzheimer’s?

• Education of patient, family, & Friends

• Promote living will and end of life care planning

• Promote financial management

• Encourage as much independence and decision making as possible

• Reduce stress

• Later in this stage is when driving, etc will need to be discussed

• Encouraged patient to stay engaged with family and friends, participate in activities

What to know about moderate Alzheimer’s ?

• Being forgetful of events or personal history.

• ​Feeling moody or withdrawn, especially in socially or mentally challenging situations.

• Being unable to recall information about themselves like their address or telephone number, and the high school or college they attended.

• Experiencing confusion about where they are or what day it is.

• Requiring help choosing proper clothing for the season or the occasion.

• Having trouble controlling their bladder and bowels.

• Experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night.

• Showing an increased tendency to wander and become lost.

• Demonstrating personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like hand-wringing or tissue shredding.

What are the nursing interventions for moderate Alzheimer’s?

• Patient safety is a priority

• Home safety list

• Strategies for wandering and other behaviors

• Encourage story telling

• This is the point that many families can no longer keep their loved ones at home

• Increasing assistance with ADLs and disease progresses

What to know about late Alzheimer’s?

• Require around-the-clock assistance with daily personal care.

• Lose awareness of recent experiences as well as of their surroundings.

• Experience changes in physical abilities, including walking, sitting and, eventually, swallowing

• Have difficulty communicating.

• Become vulnerable to infections, especially pneumonia.

What are the nursing interventions for late Alzheimer’s?

• Patient will be total care and require round the clock care

• Care for the caregivers-assist them in obtaining as much support and help as possible

• End of life decisions may need to be discussed again

What is the family’s response to Alzheimer’s disease?

• Family Response to Disorder

  • Devastating to family

  • Long-term care responsibilities

  • Managed at home

  • Wandering

  • Aggression

What is included in recovery-oriented care for a person with Alzheimer’s Disease?

• Long clinical course

• Advances quickly

• Teamwork and Collaboration: Working Toward Recovery

  • Educational and supportive programs

  • Managing cognitive symptoms, delaying cognitive decline, treating the noncognitive symptoms

  • Supporting the caregivers to improve the quality of life for both patients and their caregivers

• Safety

  • Delaying cognitive decline and supporting family members

  • Protecting the patient from injury

  • Physical needs of the patient are the focus of care

What is included in evidence-based nursing care for persons with Alzheimer’s?

• Mental Health Nursing Assessment

  • Past and present health status

  • Physical examination and review of systems

  • Physical functions

  • Self-care

  • Sleep–wake disturbances

  • Activity, exercise

  • Nutrition

  • Pain

• Psychosocial Assessment

  • Therapeutic relationship

• Mental Status and Appearance

  • Memory

  • Language

  • Executive Functioning – judgment, reasoning

  • Psychotic Symptoms

    • Suspiciousness, Delusions, and Illusions

    • Hallucinations

  • Mood changes

  • Anxiety

  • Catastrophic reaction – overreactions to every day situations

What is included in mental health nursing interventions for Alzheimer’s?

• Self-Care Interventions

  • Promotion of self-care

• Physical Health Interventions

  • Support of bowel and bladder function

  • Promotion of sleep, activity, and exercise

  • Promotion of nutrition

  • Pain and comfort management

  • Relaxation

• Pharmacologic interventions

  • Acetylcholinesterase inhibitors – help stop the decline, but don’t improve it after it is gone

  • NMDA antagonists – improves cognition

  • Memantine (Namenda) and Donepezil (Aricept) Combination

  • Other medications

    • Antidepressants and mood stabilizers – may help agitation

    • Antianxiety medications – may help anxiety (Benzos should be used with caution and for short periods oNLY)

• Psychosocial Interventions

  • Memory enhancement – work on story telling (long-term memory and short-term memory exercises)

  • Orientation – orient to current time, unless causing agitation, then redirect

    • Maintenance of language functions – word finding – help the patient by using the word for the item.

  • Supporting visuospatial functioning – put clothing in order of how it should be put on (shirt right side up, not inside out..)

• Interventions for suspiciousness, illusions, delusions – confirm reality, remove anything that can cause illusion (face in the mirror)

• Interventions for hallucinations – along with meds, reassurance and distraction

• Interventions for mood changes

  • Management of depression – remove harmful objects for concern of self harm; encourage them to discuss their feelings

  • Management of stress and anxiety – usually from feeling lost or insecure. Reduce number of choices, simplify routines, allow more control.

  • Management of catastrophic reactions – vocalize understanding of the fear/anxiety, remain calm, quiet the surroundings, softly speak to client

  • Interventions for Apathy and Withdrawal – work with family or friends to determine previous interests to try them again

• Interventions for behavioral problems

  • Management of restlessness and wandering – walking with the patient, redirecting them to location they are trying to find

  • Management of abnormal behavior – distractions work

  • Management of agitated behavior – calm, unhurried, undemanding approach works best

  • Reduction of disinhibition – redirection, adjusting to scenario

• Psychoeducation for Families

• Promoting safety – watch activities (limit those that concern safety = driving, cooking, etc); locked units

• Implementing Milieu Therapy – play it by ear! Don’t want to overstimulate, as this can agitate.

• Socialization Activities – eliciting pleasant memories (pictures, eating favorite foods, listening to music); structured exercise, pet therapy (stuffed animals)

• Evaluation and Treatment Outcomes – goal #1 is to remain at the highest level of function – remain independent as long as possible

• Continuum of Care

  • Inpatient-Focused Care

  • Community Care – community-based services (home health aides, adult day cares, respite care)

  • Nursing Home – SNF ”skilled nursing facility” – locked units if necessary

• Integration with Primary Care

What are the other types of dementia?

• Vascular dementia (multi-infarct dementia) – blockages reduce blood flow to the brain, which causes damage/destruction of brain tissue

• Dementia caused by other conditions

  • Parkinson disease – 75% of those with Parkinson’s will develop this

  • Huntington disease – typically frontal dementia

• Frontotemporal neurocognitive disorder – apathy, disinhibition, inappropriate behavior.

• Neurocognitive disorder with Lewy bodies – 5-7 yr survival rate, spontaneous parkinsonism characteristics. High risk for falls – syncopal episodes.

• Neurocognitive disorder due to Prion disease – prion = small infectious particle that causes progressive neurodegeneration. No tx. Mad cow disease, Creutzfeldt-Jakob disease.

• Neurocognitive disorder due to traumatic brain injury – mild TBI is risk factor for developing dementia.

• Substance/medication-induced neurocognitive disorder – persisting effects of a drug or toxin