Neurocognitive Disorders

• Neurocognitive Disorders

• Delirium

  •  Short-term

  •  Episodic

  •  Temporary malfunction

•  Dementia

  •  Cognitive decline

  •  Several types

  •  Gradual and permanent loss

Delirium

•  A disturbance in attention that develops over a short period of time, with an additional disturbance in cognition.

•  Prevalence increases with age to about 14% among those older than 85

•  Increase risk post-op in older adult clients, approx. 15-53%

•  60% in post acute and nursing home settings

•  83% in end-of-life setting

• Dementia and Major Neurocognitive Disorders

• Dementia is frequently used to describe neurocognitive disorders

• defined by the American Psychiatric Association as significant cognitive decline from previous level of performance in one or more cognitive domains. (complex attention, executive function, learning and memory, language, perceptual motor, or social cognition)

• These deficits interfere with independence in everyday activities and do not occur exclusively in the context of a delirium or is not better explained by another disorder.

• Manifestations typically begin with mild cognitive deficits and then progress

• Delirium onset 

• Hours to days

• Dementia onset

• Months to years

• Delirium Contributing factors

• Dehydration, hypoglycemia, fever, infection, hypotension, drug reaction, head injury, polypharmacy.

• Dementia Contributing factors

• Alzheimer’s disease, vascular disease, HIV infection, traumatic brain injury, chronic substance abuse, neurological disorders

• Delirium Cognition

• Impaired memory, judgment, attention, calculations

• Dementia Cognition

• Impaired memory, judgment, attention, calculations, abstract thinking, agnosia

• Delirium Level of Consciousness

Altered

• Dementia Level of Consciousness

• Not altered

• Delirium Activity level

• Varies, restlessness, sundowning, sleep disruption

• Dementia Activity level

• May have sundowning

• Delirium Emotional state

• Rapid mood swings; can be aggressive, fearful, anxious, paranoid (suspicious), and have hallucinations or delusions

• Dementia Emotional state

• Flat affect, delusional

• Delirium Speech and language

• Rambling, inappropriate, rapid, incoherent

• Dementia Speech and language

• Slow and incoherent, repetitious, inappropriate

• Delirium Prognosis

• Can be reversed with intervention

• Dementia Prognosis

Progresses

• Neurocognitive Disorders (DSM-5 Categories)

• Alzheimer’s disease

• Frontotemporal lobar degeneration

• Lewy body disease

• Vascular disease

• Traumatic brain injury

• Substance/medication use

• HIV infection

• Prion disease

• Parkinson’s disease

• Huntington’s disease

• Other medical conditions/multiple etiologies/unspecified

• Delirium 

• The etiology of delirium is that neurocognitive disturbances can develop over time, can fluctuate, and often worsen in the evening and night when external orienting stimuli decrease. Delirium is often associated with sleep-wake cycle disturbances and emotional disturbances such as anxiety, depression, anger, irritability, fear, euphoria, and apathy — often with rapid and unpredictable shifts in emotional states (APA, 2013).

• Older adult clients are more susceptible to delirium than younger clients, as younger clients’ delirium is usually related to fever or certain medications (such as anticholinergics).

• Delirium is highest among hospitalized older adult clients — and can vary by setting, sensitivity of detection method, and individual client characteristics (APA, 2013).

• Manifestations of delirium include irritability, confusion, hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile).

• Delirium – Etiology

•  Intoxication or withdrawal

  • • Alcohol, cannabis, phencyclidine, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, amphetamines, and cocaine

• Drugs

  • • Lithium, levodopa , steroids, digitalis, benzodiazepines

  • • CNS depressants

• Stress

• Sleep deprivation

• Emotional disturbances

• Delirium- Comorbidities

• Dehydration 

• Electrolyte imbalance 

• Infection

• Hepatic encephalopathy

• Metabolic disorders 

• B12 deficiency

• Causes of Delirium I WATCH DEATH

•  I = Infection

•  W = Withdrawal

•  A = Acute metabolic

•  T = Trauma

•  C = CNS pathology

•  H = Hypoxia

•  D = Deficiencies

•  E = Endocrinopathies

•  A = Acute vascular

•  T = Toxins or drugs

•  H = Heavy metals

• Alzheimer’s – Etiology 

•  Related to the accumulation of amyloid plaques outside ant between neurons, cortical atrophy, ant neurofibrillary tangles within the cells (APA, 2013)

•  Presence of amyloid plaques

•  Age is the strongest risk factor

• More prevalent in women

•  Prolonged androgen deprivation therapy increase risk in men

•  Populations at risk

  •  Traumatic brain injury

  •  Down syndrome

  •  Vascular disease

• Vascular Disease Dementia – Etiology

• The second most common cause of neurocognitive disorder after Alzheimer’s disease. Cognitive deficits are related to cerebrovascular events, and evidence of decline is usually seen in attention processing speed and frontal-executive function The duration of this disease varies, and plateaus are common. The risk of vascular disease increases exponentially after age 65. (APA,2013)

•  Deficits with blood vessels

  •  Hypertension

  •  Reduced blood flow to the brain

  •  Cerebrovascular “events”

  •  Risk increase exponentially after age 65

• Lewy Body Dementia – Etiology

• Often, clients with this disorder experience tactile hallucinations, which prompt the client to try to touch the object they are hallucinating. Clients have reported that the object does not disappear when touched. The hallucinated object can feel solid, and either hot or cold (Ukai, 2019, p. 1)

•  The difference between Lewy body disease and Parkinson’s disease is that clients who have Parkinson’s disease have pathology primarily in the basal ganglia, while with Lewy body disease, cognitive decline precedes motor manifestations by at least a year (APA, 2013, p. 619).

•  Like Alzheimer’s disease, Lewy body disease progression may have plateaus but always ends in severe dementia and death.

• Frontotemporal Lobe Dementia – Etiology

•  Family history

  •  40%

•  Genetic mutations

•  Because this disorder affects clients at an

• early age, there are few co-morbidities

• Other Dementia - Etiology

• TBI

•   Injury to brain

•  HIV

•   Infection with virus

•  Prion

•   Genetic

  •  Eating contaminated meat

•  Substance Use

  •  i.e. Alcohol use, cocaine use, etc.

  •  Cortical thinning seen on MRI

•  Huntington’s

  •  Genetic

•  Parkinson’s

  • Destruction of the globus pallidum

• Clinical Manifestations dementia

• Manifestations typically begin with mild cognitive deficits and then progress to more major deficits. Thus, what may start at mere forgetfulness can progress to needing round-the-clock supervision. Baseline and subsequent assessments provide documentation of decline and affect the prognosis for plan of care.

• DEMENTIA - MANIFESTATIONS

  •  5 Domains

•  Executive function

  •  Planning

•  Complex attention

  •  Processing speed

•  Learning/memory

  •  Short-term

•  Perceptual /motor

  •  Every day tasks

•  Social cognition

  •  Insensitive to standards

• Dementia – Executive Function

• Executive function involves planning, decision making, responding to feedback, working memory, mental flexibility, and overriding habits

  • Major manifestations

    • - Stops complex projects, focuses on one task at a time

    • - Needs others to plan activities and make decisions

  • Mild manifestations

    • - More effort needed to complete multistage projects

    • - Difficulty multitasking

• Dementia – Complex Attention

• Complex attention refers to sustained attention, divided attention, selective attention, and processing speed.

• Major manifestations

  • • Difficulty in environments with multiple stimuli, is easily distracted by competing events in environment.

  • • Needs simple and restricted input

  • • Thinking takes longer, processing slowed

• Mild manifestations

  • • Normal tasks take longer, need more double-checking

  • • Can think better without distractions such as TV, driving, etc.

• Dementia – Learning/Memory

• Immediate, recent memory, and very long-range memory are affected.

• Major manifestations

  • • Repeats self in conversation

  • • Cannot keep track of short list of items when shopping or planning

• Mild manifestations

  • • Difficulty recalling recent events

  • • Needs reminders and Lists.

• Note: Except in severe forms of major neurocognitive disorder, semantic, autobiographical, and implicit memory are relatively intact, compared with recent memory.

• Dementia – Language

• Major manifestations

  • - Significant difficulties with expressive or receptive languages

  • - Uses pronouns rather than names and general use words like “that thing”

• Mild manifestations

  • - Noticeable word-finding difficulty. Substitutes general for specific names of Acquaintances

  • - Subtle grammatical errors

• Dementia – Perceptual/Motor

• Major manifestations

  • • Significant difficulties with previously familiar activities and environment

  • • Often more confused at dusk

  • • Trouble with facial recognition

  • • Trouble drawing simple figures

• Mild manifestations

  • • Relies more on maps and others for directions

  • • Uses notes

  • • Frequently lost if not concentrating on task

  • • Less precise in parking

  • • Greater effort for spatial tasks

• Dementia – Social Cognition

• Social cognition refers to recognizing emotions, being able to theorize what others are thinking.

  • Major manifestations

    • • Insensitivity to social standards of modesty and topics of conversation

    • • Makes unsafe decisions

  • Mild manifestations

    • • Subtle behavior or attitude changes

    • • Decreased empathy and inhibition, restlessness

• ALZHEIMER’S DISEASE (DSM-5)

•  There must have been an insidious onset, followed by a gradual progression, and at least two domains must be impaired.

•  Major

  •  Evidence of a genetic mutation from genetic testing and/or family history, plus all of the following criteria.

    •  Evidence of memory and learning decline, and at least one other cognitive domain

    •  Gradual, but steadily progressive decline in cognition, without any extended plateaus

    •  No evidence of mixed etiology

•  Mild

  •  Evidence of a genetic mutation from genetic testing and/or family history, plus all of the following criteria.

    •  Evidence of memory or learning decline

    •  Gradual but steadily progressive decline in cognition, without any extended plateaus

    •  No evidence of mixed etiology

• Mild – Early-Stage Dementia

• •Disease is not obvious (friends and family notice subtle changes)

• •Misplaces objects, forgets names

• •Trouble with planning /organizing

• •Makes up words (neologisms)

• Moderate – Mid-Stage Dementia

• •Confused about place/time

• •Needs help with routine tasks like dressing appropriately

• •Confabulate (make up stories when they can’t remember)

• •Wandering

• •Sundowning

• •May have language difficulties

• Severe – Terminal/Late-Stage Dementia

• •Difficulty communicating, responding to their environments, and controlling movement; for example, to eat, sit, or walk.

• •Behavior that is atypical (hostility)

• •Agraphia, hyper-metamorphosis, and hyperorality may manifest

• •Needs help with ADLs

• •Needs assistance sitting up

• 6 A’s of Alzheimer’s Disease

• Amnesia- loss of memories

• Anomia- unable to recall names of everyday objects

• Apraxia- unable to perform tasks of movement

• Agnosia- inability to process sensory information

• Aphasia- disruption with ability to communicate

• Anosmia - Inability to smell

Amnesia

 loss of memories

Anomia

• unable to recall names of everyday objects

Apraxia

• unable to perform tasks of movement

Agnosia

• inability to process sensory information

Aphasia

• disruption with ability to communicate

Anosmia

• Inability to smell

• Frontotemporal Lobar Degeneration Dementia (DSM-5)

•  Neurocognitive disorder with insidious onset and gradual progression with three behavioral variants plus a decline in social cognition and/or executive ability

  •  Disinhibition, apathy, inertia, loss of sympathy/empathy, perseverative/stereotyped/compulsive/ritualistic behavior, or hyperorality and dietary changes

• OR

•  Language variant plus learning and memory problems

  •  Decline in speech production, word finding, object naming, grammar, or word comprehension (APA, 2013)

•  A client with this diagnosis will have trouble with behavior, cognition, and communication. Forty percent of clients with this disorder have family members who have had this disorder, so there appears to be some genetic connection (APA, 2013). This disorder typically affects clients at a younger age, and since it can manifest as socially inappropriate language and behavior, it can cause functional impairments in the workplace and at home.

• Lewy Body Dementia

•  Core diagnostic features

  •  Include fluctuating cognition

  •  Recurrent visual hallucinations

  •  Spontaneous features of parkinsonism

  •  Rapid eye movement sleep behavior and severe neuroleptic sensitivity can be suggestive

•  Men usually present with rapid eye movement sleep behavior as the first manifestation, while women more often present with hallucinations. (Utsumi et al., 2020)

•  Often, clients who have this disorder experience tactile hallucinations, which prompt the client to try to touch the object they are hallucinating.

•  Always ends in severe dementia and death

• Vascular Disease Dementia – Manifestations

• Cognitive decline

• Decreased processing speed

• Impaired executive function

• TBI– Manifestations

• Loss of consciousness

• Posttraumatic amnesia

• Disorientation and confusion

• Neurological signs

• Recovery may vary depending on the circumstances of the injury, age, history of brain damage, and substance abuse

• The Care Team Members

•  Providers

•  Psychologists

•  Nurses

•  Assistive personnel

•  Recreational therapists

•  Adult day care providers

•  Security/emergency response personnel

•  Therapists

  •  Speech, music, physical, occupational

•  Social workers

•  Hospice – for end-of-life care, start early

• Nurse’s Role

• Advocacy

  • •Least restrictive environment

• Safety

  • •Home and inpatient

  • •Report to adult protective services if home environment is unsafe

• Teaching

  • •Involve family and caregivers

• Therapeutic presence

  • •Therapeutic use of self

  • •Compassion, active listening, providing support for client &

• Communication

  • •Calm tone, reinforce reality, short simple phrases, limit choices

• Safety Measures – Home

• Ensure supervision 

• Remove sharp objects

• Ensure hot water and oven safety

• Prevent elopement/place tracking device

• Remove smoking material

• Evaluate house for safety hazards (poorly placed furniture, throw rugs, etc.)

• Assure locks and windows are secure

• Install safety rails on hallways, steps, bathroom, etc.

• Restrict or forbid use of the car/arrange transportation services

• Notify law enforcement, as needed of need for monitoring/chance of wandering

• Note how to contact important people (spouse, child, EMS, etc.)

• Explore installing sensor devices and web-based GPS system/bed monitor

• Safety Measures – Inpatient

• Make sure that clients have access to hearing aids and eyeglasses .

• Minimize mirrors, which can increase agitation.

• There should be railings in hallways and grab bars in bathrooms to facilitate balance.

• Make sure units are well-lit to minimize misinterpretation of shadows.

• Ensure that all clients wear identification bracelets (and possibly monitors) so their identities are clear if they leave the unit.

• When clients become agitated, judicious use of antianxiety medications may be needed.

• Using restraints with clients who are confused should be minimized, as this promotes anxiety.

• Recognize Cues: Comprehensive Assessment

•  Mood

•   Safety, depression, hostility suicidality

•  Cognition/perception

  •  Hallucinations, confabulations

•  Physical needs

  •  ADLs, self care

•  Communication

  •  Neologisms, word finding

•  Physical symptoms

  •  Anosmia, tremors, sweating, hyperactivity, nausea/vomiting

  • Mobility

  • Vital signs

•  Diagnostic/laboratory tests

Delirium cues

•  Hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile)

•  Alzheimer’s cues

•  Neologisms, perseveration, confabulation, apraxia, agnosia, agraphia, hypermetamorphosis, and hyperorality.

•  Safety, as manifestations frequently worsen at night (sundowning) when the client may not be supervised well.

•  Fronto temporal lobar cues

• Risky and socially inappropriate behaviors that may affect client safety

•  Lewy body cues

• Cognitive impairment, visual hallucinations, and rapid eye movement sleep behavior disorder

•  Drug-induced cues

•  Irritability, anxiety, sleep disturbance, dysphoria, apathy, hypersomnia, incoordination, ataxia, motor slowing, and loss of emotional control

Vascular cues

•   Cognitive decline, signs of stroke

TBI cues

•  Seizures, visual field cuts, anosmia, hemiparesis

HIV cues

• Cognitive decline

•  Fever, headache, muscle and joint pain, rash, diarrhea, weight loss, cough, night sweats, sore throat, mouth sores, and swollen lymph glands

Prion cues

•  Myoclonus, ataxia

•  Parkinson’s cues

•  Apathy, depressed mood, anxiety, hallucinations, delusions, personality changes, rapid eye movement sleep behavior disorder, daytime sleepiness

Huntington’s cues

• Bradykinesia, chorea, executive function

Delirium diagnostics

• • Chem panel

Alzheimer's diagnostics

• • Positron emission tomography (PET ) to detect amyloid plaques. Best indicator of diagnosing

• Alzheimer’s disease staging

• • MMSE to determine stage of Alzheimer’s

• • 22 to 26 = mild

• • 18 to 20 = moderate

• • 0 to 10 = severe

• • Functional assessment tool

  • • Assess function to determine stage/level

  • • Allows family members to quickly assess the needs of their loved ones

• Frontal, temporal, lobar diagnostics

• • CT MRI

• Lewy body diagnostics

History

Vascular diagnostics

• • CT, MRI, history, physical exam

• Substance use diagnostic

• • History

• • Labs to detect current use

• • MRI

HIV diagnostics

• • Labs to detect virus

Prion diagnostics

• • Biopsy or Autopsy

• • History of exposure

• Parkinson’s diagnostics

• • History of motor deficits

• Huntington’s diagnostic

• • Genetic testing

• TBI Diagnosis

•  CT, MRI

•  Manifestations

  •  Traumatic amnesia

  •  Confusion

  •  Disorientation

  •  Loss of consciousness

  •  Posturing

•  Recovery may vary depending on the circumstances of the injury, age, history of brain damage, and substance abuse (APA, 2013).

• Mild TBI

• Loss  of consciousness- less than 30 min

• Posttraumatic amnesia- less than 24 hr 

• Disorientation and confusionat initial assessment - 13 to 15 

• Moderate TBI

• Loss  of consciousness- 30 min to 24 hr 

• Posttraumatic amnesia- 24hr to 7 days 

• Disorientation and confusionat initial assessment- 9-12

• Severe TBI

• Loss  of consciousness- more than 24 hr

• Posttraumatic amnesia- more than 7 days 

• Disorientation and confusionat initial assessment- 3-8

• The 3 D’s: Delirium, Depression, Dementia

• ❖ Delirium is reversible, acute, and self-limiting.

• ❖ Depression can be treated with medication and psychotherapy.

• ❖ Dementia is a progressive disorder that worsens. While all dementia diagnoses, by definition, have met the criteria for major or mild neurocognitive disorder and have insidious onset and gradual progression, other factors are used to classify them further.

• Take Actions – Nonpharmacologic

• Education/support groups

• Personal care 

  • - Bathing, dressing eating, toileting

• Music/reminiscence therapy

  • - Improves self esteem, depression

• Safety

• Personal Care

• Clothes should be easy to put on and take off

  • • Choose clothes for patient ahead of time

  • • Label with client name

• Monitor food and fluid intake

  • • Use finger foods, check for pocketing

  • • Weigh weekly

  • • Music may help appetite

  • • Consider food delivery services

• Support independence with ADLs as long as possible

• Encourage use of hearing aids as needed

  • • Shown to decrease risk of cognitive decline in men

Diet

•  Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND)

  •  DASH + Mediterranean

    •  Flavanols (olive oil, tea, beans, wine, kale, broccoli, spinach, oranges, tomatoes, and pears)

    •  Omega-3s (ex: fish/seafood, flaxseeds oil, flaxseeds, nuts, clams, crab, lobster, mussels, oysters, shrimp and leafy vegetables)

    •  Shown to delay progression

• Take Action - Pharmacologic

Delirium

• • Treat cause

• • Benzodiazepines for delirium tremens (DTs)

• Take Action - Pharmacologic

• • Alzheimer’s

• • Symptoms

• • Cholinesterase inhibitors: donepezil, tacrine,

  • rivastigmine, and galantamine

• • Progression

  • • Aducanumab

• Take Action - Pharmacologic

  • • Other dementias

• • Target cause or symptoms

  • • Antidepressants, antipsychotics (Lewy body)

  • • Statins, anticoagulants, aspirin (vascular disorders)

  • • Levodopa, COMT inhibitors (Parkinson’s)

  • • Antiretrovirals (HIV)

  • • Tetrabenazine (Huntington’s)

• Evaluate Outcomes

• Assess for changes in cognition/behavior frequently

• Assess for caregiver strain

• Assess for medication adherence/effectiveness

• evaluate clients with neurocognitive disorders frequently, as both their manifestations and their safety can change over time