neurocognitive disorders

cognition

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

• allows one to be aware of oneself in relation to others

memory

facet of cognition, retaining and recalling past experiences

delirium

acute cognitive impairment with rapid onset caused by medical condition

dementia

chronic cognitive impairment; differentiated by cause not symptoms

sundowning

tendency for an individuals mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night

aphasia

loss of language ability

types of aphasia

• expressive

• receptive

expressive aphasia

cannot find the words to express ideas

• brocas area

receptive aphasia

cannot interpret what is said (wernicke’s)

apraxia

loss of purposeful movement

agnosia

loss of ability to recognize objects

confabulation

unconscious creation of stories or answers in place of actual memories (maintains self esteem)

perservation

persistent repetition of a work, phrase, or gesture

hyperorality

tendency to put things in the mouth to taste and chew

DSM 5 neurocognitive disorders

• delirium

• major neurocognitive disorders

• mild neurocognitive disorders

delirium

disturbance in attention and awareness

• acute onset (hours to few days); change from baseline; fluctuates with periods of lucidity over course of 24 hour day

• direct physiological cause

what else can you experience with delirium

• memory deficit

• disorientation

• language changes

• visuospatial ability

• delusions and hallucinations (usually visual)

• disturbances in sleep-wake pattern

causes of delirium

• medications

• infections

• fluid and electrolyte imbalances

• hypoxia/ischemia

• brain alterations

  • reduction in cerebral functioning or brain metabolism

  • increased plasma cortisol level

  • neurotransmitter imbalance

  • damage to enzyme systems, blood brain barrier, or cell membranes

four cardinal features of delirium

1. acute onset and fluctuating course

2. reduced ability to direct, focus, shift, and sustain attention

3. disorganized thinking

4. disturbance of consciousness

cognitive and perceptual disturbances

• illusions

• hallucinations

outcomes criteria/prioritize hypothesis

• patient will remain safe and free from injury

• during periods of clarity, patient will be oriented to time, place, and person

• patient will remain free from falls and injury while confused, with nursing safety measures

• patient and family verbalize understanding of the cause, course of illness, and treatment regimen

planning/generate solutions

• ensure necessary aids and supportive home team

• visual cues in the environment for orientation

• continuity of care providers

nonpharmacological nursing interventions for delirium: orientation

• encourages to express fears and discomfort

• comfort measures to instill trust

• frequent verbal orientation

• frequent brief interaction

• attempt consistency in nursing staff

• allow television during day with daily news

• play nonverbal music

• approach patient slowly and from the front and address patient by name

nonpharmacological nursing interventions for delirium: environment

• adequate lighting

• easy to read calendars and clocks

• reasonable noise level: decrease stimulation esp at night

• sleep hygiene; minimize disruptions, lower lighting

• provide safety; physical (lower bed and careful supervision)

• provide symptomatic and supportive care (hydration, nutrition, comfort and pain control, reassurance and companionship to instill trust

pharmacological interventions for delirium

• medicate with very small doses of antipsychotics

• benzodiazepines: lorazepam (watch for opposite action of agitation - if hepatic dysfunction use these instead of antipsychotics)

• sleep aids: mirtazapine (Remeron)

• pain control: assess objectively; consider intermittent narcotics

• identify possible drug-drug interactions: 10 meds = 100% chance of a drug-drug interaction

• must treat the underlying cause

communication

• use short, simple sentences

• speak slowly and clearly, pitching voice low to increase likelihood of being heard; do not act rushed, do not shout

• identify self by name at each contact; call client by their preferred name

• repeat questions if needed, allowing adequate time for response

• point to objects or demonstrate desired actions

• tell clients what you want done - not what to do

• listen to what the client says and observes behaviors to identify the message, emotion, or need being communicated

• educate the client (when not confused) and family

• encourage to express fears and discomfort

• frequent, brief verbal orientation

dementia

degenerative, progressive neuropsychiatric disorder that results in cognitive impairment, emotional and behavioral changes, physical and functional decline, and ultimately death

factors of neurocognitive disorders

• progressive deterioration of cognitive functioning and global impairment of intellect

• no change in consciousness

• condition is acquired; not developmental

• difficulty with memory, problem solving, and complex attention

• affects orientation, attention, memory, vocabulary, calculation ability, and abstract thinking

mild neurocognitive disorders

does not interfere with ADLs; does not necessarily progress

major neurocognitive disorders

interferes with daily functioning and independence

types of major neurocognitive disorders

• alzheimers disease

• frontotemporal dementia

• dementia with lewy bodies

• vascular dementia

• traumatic brain injury

• substance induced dementia

• HIV infection

• prion disease

• parkinsons disease

• huntingtons disease

alzheimers disease

disturbances in executive functioning

• progressive deterioration, eventually fatal

• irreversible

• not a normal part of aging

• early onset - before age 65

symptoms of alzheimers disease

• aphasia (expressive and receptive)

• apraxia

• agnosia

  • mini mental status exam (MMSE) - can’t name pencil, watch, show

• sundowning

memory impairment of alzheimers disease

• confabulation

• perservation

• hyperorality

• hoarding

risk factors of alzheimers disease

• age and family history

• CVD

• social engagement and diet

• head injury and traumatic brain injury

• HTN and dyslipidemia

biological factors of alzheimers disease

• neuronal degeneration

• genetics

• oxidative stress and free radicals

• inflammation

hallmarks of pathological diagnosis

• tau proteins and beta-amyloid plaques create neurofibrillary tangles

  • amyloid plaques: sticky clumps between nerve cells

• neurofibrillary tangles: abnormal collections of protein threads inside nerve cells

• brain atrophy

neurotransmitters implicated in AD

• acetylcholine

• glutamate

acetylcholine

• involved with learning, memory, and mood; as AD progresses the brain produces less acetylcholine

• cholinesterase inhibitors keep the acetylcholinesterase enzyme from breaking down acetylcholine

glutamate

• involved with cell signaling, learning, and memory; in AD there is excess glutamate

• NMDA antagonists helps reduce excess calcium by blocking some NMDA receptors

stages of AD

• mild

• moderate

• severe

mild AD

• forgetfulness

• misplaced articles

• decreased recall

• social withdrawal

• frustrated with self

• changes may not be apparent to others

moderate AD

• decreased ability for self-care

• way finding

• disoriented to time and place

• wandering, pacing, possible hallucinations or delusions begin

• decreased visual perception leading to accidents

• needs supervision

• emotional lability - big swings

• symptoms noticeable

severe AD

• cannot care for self

• loss use of language

• minimal long-term memory

• constant complete care

cognitive assessment tools

• mini mental state examination (MMSE)

• dementia severity rating scale

• geriatric depression scale

• memory impairment screen

• mini-cog (comprised of three sections; word recognition, clock drawing, and word recall)

• functional assessment staging tool (FAST)

nursing cues of dementia: biologic domain

• past and present health status (compare to norms)

• physical examination and review of systems

  • VS, neurologic status, nutritional status, bladder and bowel function, hygiene, skin integrity, rest and activity, sleep patterns, and fluic and electrolyte balance

nursing cues of dementia: physical functions

• self-care

• sleep-wake disturbances

• activity and exercise

• nutrition

• pain

nursing assessment for dementia

• confabulation

• preservation (repetition of phrases or gestures long after stimulus is gone)

• agraphia

• hyperorality

• aphasia, apraxia, agnosia

• sundowning/sundown syndrome

psychological cues

• suspiciousness, delusions, and illusions

• hallucinations

• mood changes

• anxiety

• catastrophic reactions

defense mechanisms

• denial

• confabulation

• perservation

• avoidance of questions

behavioral responses

• apathy and withdrawal

• restlessness, agitation, and aggression

• aberrant motor behavior

• disinhibition

• hypersexuality

• signs of stress, anxiety

social domain

• social system

• spiritual assessment

• legal status (guardianship)

• quality of life

• primary caregiver support essential to well-being of person with dementia

diagnostic tests for AD

• computed tomography scan (CT)

• positron emission tomography (PET)

• mental status questionnaires

  • mini mental state exam

• complete physical and neurological exam

• complete medical and psychiatric history

• review of recent symptoms, meds, and nutrition

nursing diagnoses

• impaired sleep

• risk for injury (wandering)

• self care deficit

• anxiety

• confusion

• impaired verbal communication

• hopelessness

• caregiver stress

• anticipatory grief

priority care issues with dementia

will change throughout course of disorder

• initially, delay cognitive decline

• moderate level: protect patient from hurting self

• late stages - physical needs become the focus of care

interventions for confusion/agitation

• speak clearly, slowly, and directly

• dont approach from behind

• face patient and call them by name every time

• use of para-verbal and nonverbal communication techniques

• walk or walk/talk with patient if they are restless

• picture albums of pets, wildlife, scenery

• music that patient likes

• patience

interventions for self-care

• maintaining independence as much as possible

• oral hygiene

interventions for nutrition

• monitoring patients weight, oral intake, and hydration

• well-balanced meals

• observation for swallowing difficulties

general nursing interventions

• supporting bowel and bladder function

• sleep interventions

• activity and exercise: balance activity with sleep

• pain and comfort management: assess carefully, so not rely on verbalized pain

• relaxation

AD medications

• acetylcholinesterase inhibitors (AChEl)

• NMDA antagonists

acetylcholinesterase inhibitors (AChEl)

• used to delay not decrease cognitive decline

  • used to stabilize memory, language, and orientation

• most common side effects: nausea, vomiting

• peaks in 3 months but continues to delay decline

acetylcholinesterase inhibitors (AChEl) examples

• galantamine - for mild-moderate AD

• donepezil and rivastigmine PO or transdermal patch

NMDA antagonists

• restore function of damaged nerve cells and reduce abnormal excitatory signals of the NT glutamate

• mild side effects of dizziness, confusion, headaches, and constipation

NMDA antagonists example

memantine

memantine

• blocks glutamate from NMDA receptors, keeping calcium from entering neurons and causing damage

medications for behavioral symptoms

• antipsychotics - may increase risk of mortality; use with extreme caution

• antidepressants

• antianxiety

• anticonvulsants