Topic 5: Neurocognitive Disorders

delirium, mild neurocognitive disorders, major neurocognitive disorders

what are the types of neurocognitive disorders

neurocognitive disorders

defits in one or more of the 6 cognitive domains are experienced by the client with a neurocognitive disorder

1. Complex attention: the ability to focus, sustain, or shift

2. executive functioning: planning, decision-making

3. learning and memory, particularly new infromation

4. language: expressive and receptive language

5. social cognition: recognizing emotions

6. perceptual and motor ability

what are the 6 cognitive domains

delirium

acute cognitive disturbance in which clinical manifestations suddenly develop, fluctuate with periods of lucidity, and is often reversible if the causative factor is identified and treated in a timely manner, can cause permanent deficits or death if not treated promptly

cognitive impairment (dementia), meds, substance intoxication or withdrawal, infection, dehydration, hypoxia, use of restraints, sleep deprivation, poor or inadequate nutrition, sensory impairment (hearing, vision), unfamiliar environment, pain

what are common RF to delirium

impaired attention, awareness, and response to environment, disorientation and confusion to time, place, situation, and orientations (to self usually remains intact), severe memory disturbance (temporary), illusions, hallucinations (usually visual)

what are the S/S of delirium

illusions

errors in the perception of sensory stimuli; the stimulus is a real object in the environment, but the person misinterprets it, and it often becomes an object of fear and is a S/S of delirium

hallucinations

false sensory stimuli that are a sign of delirium

• Do not assume acute confusion in an older person is due to dementia

• Assess for acute onset and fluctuating levels of awareness

• Assess the person’s ability to attend to the immediate environment, including responses to nursing care

• Establish the person’s usual level of cognition by interviewing family or other caregivers

• Assess for past cognitive impairment, especially an existing dementia diagnosis, and other RF

• Identify disturbances in physiological status, especially infection, hypoxia, and pain

• Identify any physiological abnormalities documented in the EHR

• Assess VS, LOC, and neurological signs

• Assess potential for injury, especially in relation to the potential for falls and wandering

• Maintain comfort measures, especially in relation to pain, cold, or positioning

• Monitor situational factors that worsen or improve symptoms

• Assess for the availability of immediate medical interventions to help prevent irreversible brain damage

what does assessing a patient with delirium include

• Altered perception, hallucinations, disorientation, and restlessness

• Agitation

• Acute confusion

• Fever, dehydration, risk for fluid imbalance, risk for electrolyte imbalance, impaired fluid intake

• Impaired sleep

• Impaired verbal communication

what are the nursing diagnoses for a patient with delirium

• Preventing physical harm due to confusion, aggression, or electrolyte and fluid imbalance

• Minimizing use of restraints because they increase confusion

• Assisting with the identification and treatment of the underlying cause

• Using supportive measures to relieve distress

• Avoid frustrating patients by quizzing with orientation questions that cannot be answered

• Give prn meds for anxiety and agitation with caution

• Acknowledge the patient’s fears and feelings

• Limit decision making if frustrating or confusing to the patient

• Accept the patient’s perception or interpretation of reality and respond to the theme or feeling tone

• Use simple, direct, and descriptive statements

• Encourage significant others to stay with the client

• Provide a low-stimulation environment for a patient whose disorientation is

• Never leave a patient in acute delirium alone

what are the nursing interventions for a client with delirium

mild neurocognitive disorder

modest cognitive decline from previous levels in at least one cognitive domain that do not interfere with independence in daily activities, but compensatory strategies might be necessary like extra reminders and multiple alarms; can still take care for themselves, problem solve, and accomplish tasks and activities taht require abstract or complex attention and thought; if ti progresses to a point where the person experiences interference or impairment of general daily functioning and delirium is not present, may be an indicator that the client is experiencing dementia and is progressing to the next stage of the disease process; nearly identical to the initial presentation of Alzheimer’s Disease, but only 50% of those with these S/S progress to dementia

increased age, CV disease, head injury, TBI, repeated head trauma increases risk even more, genetics (susceptibility gene, family history, shared lifestyle factors)

what are the nonmodifiable RF for a major neurocognitive disorder aka dementia

regular physical exercise, regular “mental” exercise, social engagement, healthy diet, sufficient sleep

what are the modifiable RF for a major neurocognitive disorder aka dementia

Alzheimer’s disease

what is the most prevalent primary dementia

Alzheimer’s disease

disease with a slow, insidious onset typically after age 65 that causes a progressive cognitive decline, and ultimately, the client succumbs to the disease; there is no cute and this is not a normal part of aging

mild (early) Alzheimer’s

which stage of Alzheimer’s:

difficulty remembering recent conversations, names or events, apathy, and depression, challenges in performing tasks in social or work settings, forgetting material that one has just read, losing/misplacing a valuable object, increasing trouble with planning/organizing

moderate (middle) Alzheimer’s

which stage of Alzheimer’s

impaired communication, disorientation, confusion, poor judgment, and behavioral changes, forget events or their personal history, become moody/withdrawn, unable to recall address or phone number, become confused on where they are and what day it is, need help for choosing proper clothing, change sleep patterns, at risk of wandering and becoming lost, become suspicious and delusional or compulsive

Severe (Late) Alzheimer’s

which stage of Alzheimer’s

difficulty speaking, swallowing, and walking, unable to respond to their environment, carry on conversation, and control movement, require full-time around-the-clock assistance with ALDs and personal care, lose awareness of recent experiences and their surroundings, experience changes in physical abilities, become vulnerable to infections (especially pneumonia)

aphasia, agraphia, agnosia, apraxia, confabulation, perseveration, hyperorality, sundowning

what are the client manifestations of Alzheimer’s disease

aphasia

S/S of Alzheimer that is the loss of language ability

agraphia

S/S of Alzheimer that is the diminished ability and eventual inability to read or write

agnosia

S/S of Alzheimer that is the inability to identify familiar objects or people

apraxia

S/S of Alzheimer that shows if a client needs repeated instruction and direction to perform the simplest tasks

confabulation

S/S of Alzheimer that is the creation of stories or answers in place of actual memories to maintain self-esteem

perseveration

S/S of Alzheimer that is the persistent repetition of a word, phrase, or gesture that continues after the original stimulus has stopped

sundowning

S/S of Alzheimer that is the tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night

hyperorality

S/S of Alzheimer that is the tendency to put everything in the mouth and to taste and chew

atrophy of the cerebral cortex, B-amyloid plaques interfere with signals between neurons, neurofibrillary tangles disrupt communication within the neuron, ventricles enlarge by default as the cortex decreases in size

what brain changes occur in a patient with Alzheimer’s

aggressive behavior and depression

what are common comorbidities with Alzheimer’s

antipsychotics can increase risk of stroke and death and benzos can worsen agitation or cause excessive sedation in elderly

why should antipsychotics and benzodiazepines be used in caution to treat comorbid aggressive behavior in clients with Alzheimer’s

SSRIs and mirtazepine are the safer options, use TCAs, SNRIs, and MAOIs in caution due to the side effects

what can be used to treat comorbid depression in Alzheimer’s clients

donepezil (Aricept), rivastigmine (Exelon and Exelon Patch), galantamine (Razadyne)

what cholinesterase inhibitors are approved to treat AD and inhibit acetylcholinesterase, thereby increasing available acetylcholine

nausea, diarrhea, insomnia, muscle cramps, fatigue, anorexia

what are the SE of donepezil (Aricept) (a cholinesterase inhibitor used to treat AD)

N/V, anorexia, indigestion, weakness, diarrhea

what are the SE of rivastigmine (Exelon) (a cholinesterase inhibitor used to treat AD)

N/V, diarrhea, dizziness, HA, decreased appetite, weight loss

What are the SE of galantamine (Razadyne) (a cholinesterase inhibitor used to treat AD)

memantine (Namenda)

what NMDA receptor antagonist is used to treat moderate to severe AD

dizziness, HA, confusion, constipation

what are the SE of memantine (Namenda) (an NMDA receptor antagonist used to treat AD)

nausea, diarrhea, insomnia, muscle cramps, fatigue, anorexia, dizziness, HA, confusion, constipation

what are the SE of memantine/donepezil (Namzaric) (an NMDA receptor antagonist/cholinesterase inhibitor used to treat AD)

those with difficulty swallowing

which AD patients is rivastigmine (Exelon) useful in

wane after 1-2 years

how long do AD medications work

S/S of normal aging

Sometimes forgetting names or appointments, but remembering them later

Making occasional errors when balancing a checkbook

Occasionally needing help to use the settings on a microwave or to record a TV show

Forgetting the day of the week but figuring it out later

Vision changes related to cataracts

Sometimes having difficulty finding the correct word

Misplacing things from time ot time and retracing steps to find them

Makign a bad decision once in a while

Sometimes feeling weary of work, family, and social obligations

Developing specific ways of doing things and becoming irritable when routine is disrupted

S/S of Alzheimer’s Disease

Memory loss that disrupts daily life

Challenges in planning or solving problems

Difficulty completing familiar tasks

Confusion with time or place

Trouble understanding visual images or spatial relationships

New problems with words in speaking or writing

Misplacing things and losing the avility to retrace steps

Decreased or poor judgement

Withdrawal from social and work activities

Changes in mood and personality

Sudden (hours to days) and fluctuates over the course of the day

Slowly, over months and years

May have been gradual with exacerbation during crisis or stress

what is the onset of delirium, dementia, and depression

Underlying medical condition such as a urinary tract infection, substance intoxication, or effects of meds

Alzheimer’s, vascular disease, HIV, neurological disease, chronic alcoholism, head trauma

Lifelong history, losses, loneliness, crises, declining health, medical conditions

what is the cause/contributing factors of delirium, dementia, and depression

Impaired attention span, memory deficit, disorientations, disturbances in perception, not related to other cognitive disorders or reduced livel of arousal

Impaired memory, judgement, calculations, attention span, abstract thinking, and agnosia

Difficulty concentrating, forgetfulness, inattention

what is the cognition of delirium, dementia, and depression

Increased or reduced, restlessness, behaviors may worsen in evening (sundowning), sleep-wake cycle may be reversed

Not altered, behaviors may worsen in evening (sundowning)

Unusually decreased, lethargy, fatigue, lack of motivation, may sleep poorly and awaken in the early morning

what is the activity level of delirium, dementia, and depression

Rapid swings, fearful, anxious, suspicious, aggressive, have hallucinations/delusions

Flat, agitation

Extreme sadness, apathy, irritability, anxiety, paranoid ideation

what is the emotional state of delirium, dementia, and depression

Rapid, inappropriate, incoherent, rambling

Incoherent, slow, inappropriate, rambling, repetitious

Slow, flat, low

What is the speech and language of delirium, dementia, and depression

Reversible with proper and timely treatment

Not reversible and progressive

Reversible with proper and time treatment

what is the prognosis of delirium, dementia, and depression