Cognitive Disorders

Brain’s ability to process, retain, use information

cognition

cognitive abilities include

reasoning, judgment, perception, attention, comprehension, memory

•Disruption or impairment in higher level brain functions

cognitive disorders

Neurocognitive disorders (NCDs):

The DSM5 categorizes to include

delirium, minor NCD, major NCD, and subtypes by etiology

How the brain takes in, makes sense of, then utilizes information.

cognition-thinking process

Disruption or impairment of higher-level functions of brain (cognitive abilities/functioning)

Neurocognitive Disorders (NCDs)

with Neurocognitive Disorders (NCDs)

s/s often mimic

and its difficult to obtain

other mental illnesses

direct evidence for definitive diagnosis

 A syndrome that involves a disturbance of consciousness accompanied by a change of cognition

delirium

delirium risk factors

older adults

meds (drug intoxication)

substance use/withdrawal

infections (sepsis, pneumonia, UTI)

fluid & electrolyte imbalances: nutritional deficiencies

hypoxia or ischemia

metabolic disturbances

brain tumor/head injury

surgery

change in environment (hospitalization/ICU)

restraint use

terminally ill

goal of delirium care

Minimize risk factors in order to prevent delirium AND identify underlying cause!

is delirium reversible if diagnosed and treated promptly

yes

delirium general interventions

● Thorough initial assessment with frequent reassessments

●Eliminate or correct underlying cause

●Provide a safe environment

●Coordinate interdisciplinary treatment

●Provide symptomatic and supportive measures

delirium biological interventions

• Monitor changes

• Maintain fluid and hydration

• Promote sleep and nutrition

• Prevent aspiration and skin breakdown

• Keep eyeglasses and hearing aids readily available

• Administer medications as prescribed

delirium psychological interventions

•Provide interaction and support

•Present reality as needed

•Encourage expression of fears and discomforts

•Provide a comfortable, orienting

• adequate lighting, comfortable noise level, easy-to-read calendars and clocks, introduce oneself

•Reduce stimuli

•For confusion = Limit choices,

Restraints as last resort

delirium sociological interventions

•Utilize de-escalation techniques

•Involve family if possible

Delirium is usually _______ and ________ if caught promptly!

transient

reversible

delirium evaluation

Correction of underlying physiological alteration

Prevention of injury

Resolution of confusion and other associated behaviors

Usually return to prior level of functioning (depending on cause)

A disease process marked by progressive cognitive impairment with no change in the level of consciousness

dementia

cognitive disturbances associated with dementia

aphasia, apraxia, agnosia, disturbance in executive function

starts with the inability to name familiar objects or people and then progresses to speech that becomes vague or empty with excessive use of terms such as it or thing​

aphasia

causes the client to lose the ability to perform routine self-care activities such as dressing or cooking​

apraxia

particularly frustrating  may see a chair but be unable to name what it is​

agnosia

loses the ability to learn new material, solve problems, or carry out daily activities such as meal planning and budgeting​

Disturbance in executive functioning:

Disorders affecting neurological system that are common causes and risk factors for dementia

• Alzheimer’s disease​

• Vascular (multi-infarct) dementia​

• Lewy body dementia​

• Parkinson’s disease​

• Huntington’s disease​

• Prion Disease​

• Frontotemporal lobar degeneration(Picks diseases)

common risk factors for dementia

advanced age #1

Prior head trauma​

• Lifestyle factors (e.g., sedentary)​

• Genetics (e.g., family history ofAlzheimer’s dementia)​

• Metabolic syndrome or diabetes​

• Substance use or medication induced​

• Infections (e.g., HIV)

characterized by a marked disruption in cerebral blood flow with destruction of brain cells; blockage of blood vessels leads to brain damage and cognitive impairment; reduces life expectancy to a greater degree than AD; can occur suddenly

Vascular dementia

goal for common causes & risk factors for dementia

Minimize risk factors in order to prevent dementia!

for dementia: In Alzheimers, might target those at increased genetic risk and try to prevent such as give___________ – a vaccine is being studied in mice per Gersch.

prophylactic nutritional agents like Vit. E

dementia is an umbrella term used to describe a range of symptoms associated with cognitive impairment which include

alzheimers, vascular, lewy body, frontotemperal

impairment in consciousness and rapid change in cognition over short time period

delirium

delirium includes

• Impaired _____ and ______​

• Difficulty sustaining ______​

• Rambling, irrelevant, incoherent speech​

• Hallucinations, delusions, illusions, misinterpretations​

• ______ and confusion​

• Altered level of_______ (LOC)​

• _________ and insomnia​

• _______ and nightmares​

• Emotional instability​

• Psychomotor activity changes​

• ________ vital signs

• memory

• judgment

• attention

• Disorientation

• consciousness

• Hypersomnolence

• Vivid dreams

• Unstable

delirium is usually cause by ________

a medical condition

if delirium is caused by a medical condition

what are 3 things to note

usually reversible if cause is treated

considered an emergency

higher risk for future episodes of delirium

chronic, gradual, progressive cognitive impairments

dementia

• Impaired ___________

• Aphasia, apraxia, agnosia​

• Disturbance in executive functioning​

• -________ and _______ changes​

• _______ and ________ decline​

• Possible delirium​

• LOC usually _________

• Restlessness and agitation; “sundowning”​

• ______ vital signs unless illness occur

• memory and judgment​

• Emotional

• behavioral

• Physical, functional

• unchanged​

for dementia what are the 3 things

not related to another mental health disorder

often caused by disorders affection neurological system

usually irreversible

• late-day confusion. Confusion and agitation may get worse in the late afternoon and evening and is less pronounced earlier in the day. ​

sundowning

• Onset: rapid over short period of time (hours or days)​

• ALWAYS secondary to another condition/underlying cause​

• Often unrecognized! ​

• Older adults are highest risk​

• Impaired memory, judgment, ability to focus, & ability to calculate​

• Disorientation & confusion (often worse at night & early in morning)​

• Change in LOC (can rapidly fluctuate)​

• Psychomotor activity changes ​

• Personality change (rapid)/fluctuating moods​

• Perceptual disturbances – this change in reality can cause fear, panic and anger​

• USUALLY reversible if Dx and Tx are prompt!

delirium

what are the 4 psychomotor changes in delirium

hyperactive with agitation & restlessness;

• hypoactive with apathy & quietness;

• mixed;

• unclassified)

• Onset: Gradual deterioration of function over months or years​

• People with NCD can also develop ​

• Cognitive deficits NOT r/t another mental health disorder​

• Per Gersch, aphasia doesn’t occur until severe stages (it’s progressive, not rapid)​

• Impaired executive functioning relates to managing daily tasks​

• Personality change is gradual​

• impairments do not change throughout the day like they may fluctuate with delirium ​

• “Sundowning” - “late-day confusion.”

dementia

Loss of neurons and volume in certain brain regions​

• Beta-amyloid plaques​

• Neurofibrillary tangles​

• Cell death

Alzheimer's Disease

It is marked by global, progressive impairment of cognitive functioning, memory, and personality.

Alzheimer’s disease/dementia

Alzheimer’s disease/dementia

reversible? how to changes?

irreversible

progressive

how to diagnose Alzheimer’s disease/dementia in a living patient

rule out other causes of dementia and base on DSM-5 criteria

for Alzheimer's Disease Brain-imaging techniques have found a significant loss of

which is why it is important we do an MRI

neurons and volume in the brain regions devoted to memory and higher mental functioning

neurofibrillary tangles (i.e., twisted nerve cell fibers) and a buildup of beta amyloid plaques (a sticky protein) - seen on spinal analysis

Alzheimer's Disease

Alzheimer's Disease Neurotransmitters: Several have _________ levels (e.g., acetylcholine, dopamine, norepinephrine, and serotonin)​

decreased

Alzheimer's

• Oxidants:​

• When oxidants are -________, they can cause severe damage to cells and tissue. Oxidation is known to play a part in diseases like CAD and cancer and also AD. ​

overproduced

• _______ AND __________ like infection, metals, and toxins may trigger oxidation, inflammation and the AD process (especially if genetically susceptible). ​

genetics

environmental factors

Other possible causes/risk factors of AD

vitamin deficiencies, depression, head injury, cardiovascular disease, lower education

Changes in brain, years before signs of disease

Some mild memory loss

No impact on judgment or ability to perform ADLs

preclinical

mild (early) stages of Alzheimers Disease

_______ memory lapses​

Unable to remember _________________

Forget __________ ​

_____ or _______ items​

Impaired __________​

Problem _________ and __________​

Able to perform ______

Short-term

names of new people​

familiar words​

Lose

misplace

concentration

planning, organizing

ADLs​

moderate (middle) stages of Alzheimers Disease

__________; progressive ____________; forgetting ___________

__________ & ________ changes​

↑ difficulty ______ and ________ ​

May __________​

_____ disturbances​

May be ________​

May need help w/ _____

Confusion, memory loss, events of own history​

Behavioral, personality

planning, organizing

wander/get lost

Sleep

incontinent

ADLs​

severe (late) stages of Alzheimers Disease

Loses awareness of _______​

Loses ability to _______ w/ others​

__________​

↑ difficulty with _________

Eventually impaired ______ & total loss of ________

Needs help w/ all _____ & ________

environment

communicate

Incontinent

physical abilities​

swallowing

movement ability​

ADLs

personal care​

a person may function independently.

He or she may still drive, work and be part of social activities. Despite this, the person may feel as if he or she is having memory lapses, such as forgetting familiar words or the location of everyday objects.

Friends, family or others close to the individual begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Common difficulties include:

• Forget familiar words (difficulty coming up with right word or name)​

• Forget location of familiar or valuable objects​

• Forget material just read​

• MILD Alzheimer's

typically the longest stage and can last for many years. As the disease progresses, the person with Alzheimer's will require a greater level of care.

You may notice the person with Alzheimer's confusing words, getting frustrated or angry, or acting in unexpected ways, such as refusing to bathe. Damage to nerve cells in the brain can make it difficult to express thoughts and perform routine tasks.​

moderate alzheimer’s

• Greater difficulty performing tasks that require planning and organizing such as paying bills and managing money​

• Confusion – may forget where they are or what day it is​

• Forget events of one’s own history such as address and #, high school or college name​

• ADLs – may need help choosing proper clothes for occasion or weather; hygiene​

• Personality and behavior changes – appear withdrawn or subdued or moody, especially in social or mentally challenging situation; may be compulsive; may have repetitive actions (hand wringing; tissue shredding); may have delusions. May become suspicious.​

• Sleep – may sleep during day and become restless at night​

moderate alzheimers

In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases, but communicating pain becomes difficult. As memory and cognitive skills continue to worsen, significant personality changes may take place, and individuals need extensive help with daily activities.​

severe (late alzheimers)

• Needs round-the-clock assistance with ADLs and personal care​

• They can’t walk or sit (bedridden) and eventually can’t swallow​

• Can develop stupor and coma​

• Vulnerable to infections, especially pneumonia - Death often r/t choking or infection​

severe (late) alzheimers

Etiology of Vascular Dementia (VD) ​

Characterized by a marked disruption in _________ with destruction of _________

cerebral blood flow

brain cells

• Blocked blood vessels leads to brain damage and cognitive impairment​

• Can occur suddenly after blockage of major brain blood vessel​

vascular dementia

risk factors for vascular dementia

• Advanced age​

• Cerebral emboli or thrombosis​

• Atherosclerosis disease​

• Transient ischemic attacks or stroke​

• Diabetes, heart disease, hypertension​

• High cholesterol

reduces life expectancy to a greater degree than Alzheimer’s dementia

vascular dementia

explain the s/s of vascular dementia

• Often progressive; some S/S may occur rapidly if blockage is sudden​

• Impairments more localized (vs. global) compared to Alzheimer’s​

• Inappropriate emotional reactions (may laugh or cry inappropriately)​

• Muscle weakness – leg or arm​

• Getting lost in familiar places​

• Problem doing tasks like handling money

vascular dementia

true or false s/s may depend on the site of blockage for vascular dementia

• Disorientation or confusion​

• Dizziness​

• Recent memory loss​

• Wandering/getting lost​

• Inappropriate emotions; depression​

• Slurred speech​

• Muscle weakness​

• Problem following instructions or doing certain tasks

If sudden onset, initial symptoms may include confusion, disorientation, trouble speaking or understanding speech, and/or vision loss. Memory loss may or may not be present.

vascular dementia

More localized impairments versus global. Cerebral problems affect localized parts of the brain, sparing other brain function.

Brain damage may be so slight that symptoms are barely noticeable but over time, as more small vessels are blocked, the mental decline may become more apparent

vascular dementia

General Nursing Interventions for Dementia

Establish baseline ___________; thorough __________​

Provide __________ as needed​

• Restrict ____ when person becomes forgetful​

• Put mattress on the _____ to reduce fall risk​

level of functioning, assessment

safety interventions

• driving

• floor

General Nursing Interventions for Dementia

Establish a _________ with patient and family​

• Maintain __________ as much as possible​

• Provide ample time to perform ____ in early stages of dementia​

therapeutic relationship

• independence

• ADLs

General Nursing Interventions for Dementia

• Use ____________________ with caution​

• Avoid medication with ________ side effects​

• antipsychotics, antidepressants, mood stabilizers, anxiolytics

• anticholinergic

Safety:​

• Assess for fall risk or wandering; assign to room close to nurses’ station

nursing interventions for dementia

what can be used to ease anxiety and agitation for dementia

depression and anti anxiety (benzos)

use _______ if hallucination or delusion or to help calm agitated behavior but only as last resort due to side effects. ​

Antipsychotics

blurred vision,

constipation,

decreased sweating,

dizziness,

dry mouth,

and difficulty urinating and/or kidney failure

anticholinergic side effects

General Nursing Interventions for Dementia

• Promote patient _____ and ______

• Provide patient and family education, support and communication​

• Teach_____ safety measures​

• When individual becomes upset, teach loved ones to ____________

• dignity

• quality of life​

• home

• listen briefly, provide support, then change the topic​

General Nursing Interventions for Dementia

• Encourage ________ and ____________

• Discuss ___________ and legal counsel if needed; educate on available __________ and community resources​

• Establish __________ routines (with sleep, nutrition, hygiene, andactivity)​

• Balance ______ with sleep​

• Treat co-occurring problems​ like depression, anxiety, agitation, psychosis, deficiencies in nutrition, sleep, overall health

• respite care, family support groups​

• advanced directives

• home care

• simple, consistent

• activity

dementia

• Home safety measures (e.g., remove _____ rugs, install door ______ that can’t be easily opened, lock _____ thermostat and turn water ______to safe level; good lighting, esp stairs, handrail on stairs – mark step edges with _______; remove clutter; secure cords to baseboards; store cleaning supplies in ____ cupboards; ______ in bathrooms. ​

• Don’t move _____________– keep environment ________ as much as possible; don’t change patient’s room unless necessary​

• Provide __________ when possible​

• May need legal counsel on advanced directives, guardianship, or DPOA ​

• Resources – may include long-term care options – ___ should be last resort because change in environment increases confusion

• scatter

• locks

• water heater

• temp down

• colored tape

• locked

• handrails

• furniture or possessions around , unchanged

• consistent caregivers

• LTC