Neurological Disorders

cognitive deficits may be due to a temporary malfunction, known as ______​​​​​​​, or a gradual and permanent loss of cognitive function, known as ______

delirium, dementia

__________ represents the person's ability to process or retrieve what had previously been acquired.

Cognitive functioning

Complex attention

sustained attention,

divided attention,

selective attention,

processing speed

Complex attention major s/s

difficult concentrating with environment w. lots of stimuli.

Longer thinking and processing

needs simple and restricted input

Complex attention minor s/s

can process better without distractions

normal task take longer and more double-check

sustained attention assess

press button when tone heard

divided attention assess

tapping while listening to story

selective attention assess

count letters while hearing numbers and letters outload

process speed assess

time on task

executive function

planning

decision making

respond to feedback

working memory

mental flexibility

overriding habits

executive function major s/s

stops complex projects

focus one task at time

needs others to plan activities and make decisions

executive function minor s/s

more effort needed to complete multistage projects

difficulty multitasking

planning assess

ability to interpret a sequential picture or object arrangement/find exit

decision-making assess

tasks that involve deciding between alternatives

responding to feedback assess

infer rules from solving a problem

working memory assess

adding up a list of numbersment

mental flexibility assess

shift between two tasks, concepts, response rules (number to letter, verbal to keypress)

overriding habits assess

ability to name the color of word’s font, rather than the word

learning and memory

immediate memory, recent memory, very long-term memory

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

learning and memory major s/s

repeats self in conversation

cannot keep track of short list of items when shopping or planning

learning and memory minor s/s

difficulty recalling recent events, needs reminders and lists

immediate memory

ability to repeat lists of words or digits

recent memory

word lists, short story, diagram

language

expressive

grammar and syntax

receptive language

language major s/s

significant difficulties w/ expressive/reactive language

uses pronouns rather than names and general use words like “that thing”

language minor s/s

noticeable word-finding difficulty

substitutes general for specific names of acquaintances

subtle grammatical errors

expressive

identify objects or pictures, or words starting with certain letterGr

grammar and syntax

errors observed during naming and fluency testsr

receptive language

comprehension or performing action

perceptual-motor

visual perception

visuoconstructional

perceptual-motor

praxis gnosis

perceptual motor major s/s

significant difficulties w/ previously familiar activities and environment.

often confused at dusk

perceptual motor mild s/s

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

visual perception

facial recognition

visuoconstructional

drawing, copying, block assembly

perceptual motor

inserting blocks into a form board w/o visual cues

praxis

imitating gestures or learned movements

gnosis

recognition of faces and colors

social cognition

recognition of emotions

theory of mind

social cognition major s/s

insensitivity to social standards of modestly and topics of conversation

makes unsafe decisions

social cognition minor s/s

subtle behavior or attitude changes

decreased empathy and inhibition, restlessness

recognition of emotions

identify emotions on faces

theory of mind

story cards with questions to elicit information about mental state of people in story

delirium vs dementia vs depression onset

delirium: hours-days

dementia: months to years

depression: gradual and exacerbation w/ stress

delirium vs dementia vs depression contributing factors

delirium: dehydration, low BG, fever, infection, hypoTN, drug reaction, heat injury

dementia: Alzheimer, vascular disease, HIV, traumatic brain injury, chronic SUD, neurological disorders

depression: lifelong or related to losses, crises, health/medical conditions, loneliness

delirium vs dementia vs depression cognition

delirium: impaired memory, judgment, attention, calculation

dementia: impaired memory, judgment, attention, calculation + abstract thinking, agnosia

depression: forgetfulness, inattention, difficulty concentrating

delirium vs dementia vs depression LOC

delirium: altered

dementia: not altered

depression: not altered

delirium vs dementia vs depression activity level

delirium: varies, restlessness, sundowning, sleep disruption

dementia: may have sundowning

depression: Decreased activity, fatigue, lethargy, poor sleep, lack of motivation

delirium vs dementia vs depression emotional state

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

dementia: flat affect, delusional

depression: Sad, apathetic, anxious, irritable, inappropriate guilt, can be paranoid

delirium vs dementia vs depression speech and language

delirium: rambling, inappropriate rapid, incoherent

dementia: slow and incoherent, repetitious, inappropriate

depression: slow, low, flat

delirium vs dementia vs depression prognosis

delirium : can be reversed with intervention

dementia: will worsen

depression: medication and psychotherapy

delirium

disturbance in attention and cognition that develops over short time + disturbance of cognition

sleep-wake cycle and emotional disturbances

due to substance intoxication

substance intoxication → delirium

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

• withdrawal can lead to delirium

metabolic disorders (thyroid disorders), neurological disorders (head trauma), tumors, vitamin B-12 deficiencies, physical stressors (pain or sleep deprivation), and drugs like lithium, levodopa, tricyclic antidepressants, benzodiazepines, central nervous system depressants, digitalis, and steroids, dehydration

hepatic encephalopathy

older adult clients who are dehydrated or w/ UTI

delirium s/s

irritability, confusion, hyperactivity, trembling (DT’s, can be cause by alcohol withdrawal), tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile)

→ to death if not intervened

(use BZ, barbiturates, antipsychotics)

worsens if older, had medication, psychiatric disorder, poor diet

major neurocognitive disorder

wide range of disorders of cognitive functioning which interfere w/ ADLs

(DSM-5-TR) mild cognitive → major

DSM-5-TR disorders

Alzheimer’s disease, frontotemporal degeneration, Lewy body disease, vascular disease, traumatic brain injury, substance/medication use, HIV infection, prion disease, Parkinson’s disease, Huntington’s disease, and other medical conditions/multiple etiologies/unspecified etiology

alzheimer’s disease

from family hx

Decline in memory, learning, and cognition

insidious onset and gradual progression of impairment due to accumulation of amyloid plaques in neurons

1. evidence of memory and learning decline

2. at least one other cognitive domain decline;

   1. progressive decline in cognition;

   2. no evidence of a mixed etiology.

~10y prognosis = severe dementia → death

major Alzheimer DSM

genetic testing or family hx + :

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

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

3. No evidence of mixed etiology

minor Alzheimer

Probable Alzheimer's disease with evidence of a genetic mutation from genetic testing and/or family history and possible Alzheimer's disease with no evidence

good ADLs and communication but may displace objects or forget appointments examples:

• not choosing the right word or name,

• forgetting material that was just read or names of people just introduced,

• having difficulty performing tasks,

• having trouble planning or organizing,

• and losing or misplacing objects.

neologisms, deficit of language and memory.

keep working on healthy behaviors + make end of life decisions

Moderate Alzheimer

needs more help → frustrated, confused, angry, and irritable → trouble expressing thoughts, or simple tasks

• forgetting events or personal history,

• being withdrawn or labile (moody),

• having trouble recalling information,

• being confused about location or time,

• needing help dressing appropriately for the occasion or season,

• experiencing disrupted sleep patterns,

• having a tendency to wander or become lost

• , demonstrating behavioral changes,

• and losing bowel/bladder control.

sundown, perseverate, confabulate, aphasia, apraxia, agnosia

(repetitive verbalization or motions due to cognitive disturbance)

perseverate

make repetitive verbalizations or motions due to cognitive disturbances

confabulate

To create fabricated or distorted memories.

agnosia/ apraxia

inability to recognize objects, even though sensory ability is intact

inability to perform motor activities even though physical ability remains intact

severe Alzheimer

many cognitive losses: diff communicating, responding to environment, controlling movement

behaviors uncorrelated w/ personality

agraphia, hyper metamorphosis, hyperorality

continuous monitoring, vulnerable to infections

respite care and palliative care

+ help w/ ADL

frontotemporal degeneration dementia (Pick’s disease)

Behavioral or language issues

frontotemporal lobe damage

onset or gradual with 3 variants:

• disinhibition,

• apathy,

• inertia,

• loss of sympathy/empathy,

• perseverative/stereotyped/compulsive/ritualistic behavior, or

• hyperorality and dietary changes)

EPS: prominent, with palsy, muscle atrophy, and hallucinations

+decline in social cognition/ language variant, or learning and memory

~genetic tau (MAPT), the granulin gene (GRN), and the CNORF72 gene

+ younger age

CT/MRI

Lewy body disease dementia

fluctuating cognition, recurrent visual hallucinations (women), and spontaneous features of​​​​​​​ parkinsonism,

REM sleep behavior and severe neuroleptic sensitivity can also be suggestive (men)

tactile hallucination that do not disappear when touched

more impairments of attention, visuospatial abilities, and executive function than Alzheimer

cognitive decline before motor → ends with severe dementia and death

co-occurring w/ Alzheimer and cerebrovascular disease

Parkinson and alzeihmer’s s/s

take pt hx

vascular disease dementia

decreased blood flow to brain (2nd most common after Alzheimer)

decline in attention and frontal- executive function

duration varies

CT/MRI, physical exam, hx of CVA

difficulty clock drawing

TBI dementia

loss of consciousness, posttraumatic amnesia, disorientation, and confusion ← after injury + recovery

can mimic dementia → misdx

due to accidents (fractures present), co-occurring SUD, strangulation (interpersonal/ domestic violence)

more likely for under 4, adolescents, over 65y

SUD dementia

intoxication + withdrawal from substance that can produce neurocognitive impairment = long term

Temporal course of disorder consistent with substance use

alcohol, inhalants, amphetamines, and sedative/hypnotic/anxiolytics. methamphetamine

can increase w/ vascular disease, liver disease, nutritional deficits, cerebrovascular disease, and cardiovascular disease + after age 50y

HIV dementia

depending on HIV status, dementia worsens or betters

unprotected sexual activity, reuse of needles, infected blood products, and iatrogenic factors

prion disease dementia

infected with prion → myoclonus/ataxia

→ Creutzfeldt-Jakob disease (CJD) [bovine spongiform encephalopathy or mad cow disease], kuru, Gerstmann-Staussler-Scheinker syndrome, or fatal insomnia

=s/s = rapidly progresses to anxiety, problems with sleeping or appetite, difficulties with concentration, fatigue, lack of coordination, altered vision, abnormal movements, and progressive dementia (wing beating)

from animals, transplanted corneas, human growth factor injection, or from infected the client to the health care worker

dx w/ biopsy/ autopsy or where livestock or outbreak of madcow

NO CURE/ MED

Parkinson dementia

develop motor manifestations before cognitive

tremors, rigidity, bradykinesia, postural instability, dystonia, vocal manifestations, and gait/walking problems

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

herbicides and pesticides or have a history of traumatic brain injury.

Huntington’s disease dementia

insidious onset and gradual progression

cognitive → motor (core first) for 10y or more → difficult to understand → severe chorea (involuntary jerking)

dysarthria, impaired gait, and impulsive/irritable behaviors.

HTT gene in X 4 ( use genetic testing)

comorbidities in dementia

delirium, sleep disorders, epilepsy, oral disease, malnutrition, falls, and visual impairment.

in older adults = chronic obstructive pulmonary disease (COPD), vascular disease, diabetes mellitus

can be caused due to anticholinergics

comorbidities in Alzheimer

CV,

due to confusion → nonadherence to med

eye disease due to poor blood flow = macular degeneration, diabetic retinopathy, and glaucoma

Alzheimer risk factor

age, women (longer lives, pregnancy, low estrogen, genotype)

genetic in polymorphism apolipoprotein E4

Down syndrome, vascular disease, TBI

stress in childhood

Prolonged use of androgen deprivation therapy (ADT) in men

hyperactive or hypoactive delirium

hyperactive delirium where the person becomes overly reactive (agitated and restless),

hypoactive delirium where the client becomes underactive (sleepy, lethargic, or slow to respond). “acute apathy syndrome,”

alzheimer’s disease

ApoE4 (chromosome 19) and chromosome 21 (trisomy 21 or Down syndrome)

tangles of fibers found inside neurons accumulate proteins called tau → amyloid plaques

dementia patient interventions

consistent routines, calm environments, reorient patients w/ seasonal decorations, calendars, and clocks

delirium tests

hormone levels, vitamin levels, electrolytes, thyroid function, glucose, therapeutic drug levels, liver and kidney function, VDRL, HIV, and CBC

urine and blood tests for infection and electrocardiograms (ECG)

determine underlying cause

Alzheimer testing

for Positron emission tomography (PET) amyloid plaques, cortical atrophy, tau predominant neurofibrillary tangles

mini-mental status exam or functional assessment stage tools for stages,

FAST: 16-item: neurologic deficits of perception (such as puzzle-solving), attention span (sustaining an activity), memory (remembering something a few minutes later), emotional control (gauging whether emotions coincide with the situation), and reasoning/judgment (following social conventions and making appropriate decisions).

Stage 1 / 2 functional assessment

1: no change = normal adult

2: trouble w/ words/ location but good ADL = normal ADL

Stage 3 functional assessment

stressful setting → deficit but return when stress ends

may require assistance and monitoring

designate power of attorney

= incipient + possible Alzheimer

Stage 4 functional assessment

requires assistance w/ organizing/ planning, no housework

may abandon hobbies

minimal/ moderate assistance w/ ADL

probably needs power of attorney

=mild Alzheimer

Stage 5 functional assessment

needs prompting and assistance for hygiene/ dressing

inappropriate emotions

moderate assistance w/ ADL

power of attorney is in place

= moderate Alzheimer

Stage 6 functional assessment

must be assisted w/ dressing and bathing → incontinence,

moderate to total care/ monitor

moderately severe Alzheimer

Stage 7 functional assessment

all s/s worsen. Few words. Total care

severe Alzheimer

Stage 8 functional assessment

not able to hold head, sit, smile

fetal position + immobile

seizure, total care

= severe alzheimer

TBI severity

_________ is evident on MRIs of clients who chronically use alcohol. 

Cortical thinning

depression

lack of motivation and interest in activities previously enjoyed.

trigger and experience loneliness

Alzheimer diet prevention

Mediterranean diet: fish, fresh vegetables, and plant oils + exercise

MIND: Mediterranean-DASH

Omega 3: fish, flaxseed oil, flaxseeds, nuts, and leafy vegetables

high intake of flavanol-rich foods like olive oil, tea, beans, wine, kale, broccoli, spinach, oranges, tomatoes, and pears

Alzheimer interventions

use hearing aids

reminiscence therapy: build a scrapbook or legacy book to record important events that the client may want to remember

• self esteem for clients

music → evoke autobiographical memories

massage therapy (cranial-sacral to improve CSF), face- recognition practice, pet-therapy

monitoring for proper hydration and nutrition, daily exercise

early mobility, families in care, and restricting the use of analgesics or sedatives

when progresses: live at home but may need some assistance with reminders for appointments, wear a location device to prevent getting lost,

high locks but with caregivers present

-—> 24hr facility for supervision

unit enviroment

the safety of the client, to prevent elopement, to minimize sensory stimulation, to make pathways clear, and to facilitate viewing of the client.

minimize mirrors, railings in hallways and grab bars in bathrooms, well-light

minimize the use of restraints and instead use distraction or redirection for clients

Dementia in home

• Ensure supervision is appropriate to the stage of illness.+ monitor medication adherence.

• Consider placing the bed mattress for fall risk

• Contact important people (spouse, children, EMS).

  • Educate family on the disease, importance of monitoring, and client needs.

• Ensure adequate nutrition and hydration.

• Ensure hot water and oven safety.

• Prevent elopement/place a tracking device on the client.

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

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

  • Remove smoking materials.

  • Minimize sensory overstimulation.

  • Ensure locks and windows are secure.

  • Install safety rails on hallways, steps, and bathrooms.

  • Remove sharp objects.

• Restrict or forbid the use of the car, and arrange transportation services as needed.

• Label rooms and drawers.

• Explore installing sensor devices and web-based GPS systems/bed monitors.

• Consider meal delivery/home health aides/home health services/respite services as needed.

• Encourage activities the client enjoys and can perform well.

patient education

teach family and pt about disease: Printed handouts,

teach delirium abut self-limiting nature of disorder

Peplau: stated that the relationship between the nurse and the client is essential (therapeutic presence)

dementia take redirection well, so using distraction and anticipating the client’s needs are important to communicate empathy.

Reminiscence therapy

reinforce reality

The nurse must always assess for safety, depression, and suicidality, as well as signs of cognitive dysfunction

delirium assess

alert for manifestations of irritability, confusion, hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile).

herbs

Buckwheat honey → potential source of cholinesterase inhibition

Lemon, rosemary, and lavender essential oils → sleep, cognitive function, and memory and decrease anxiety, agitation, aggression, and psychotic manifestation

meds for s/s Alzheimer

• Mild to moderate stage: cholinesterase inhibitors (donepezil, tacrine, rivastigmine, and galantamine)

• Moderate to severe stage: IV-methyl-d-aspartate antagonist memantine and combination of memantine hydrochloride extended release and donepezil hydrochloride

meds for disease progression

aducanumab: reduce amyloid beta plaques for early stage