Chapter 17: Neurocognitive Disorders (Week 8)

Chapter 17: Neurocognitive Disorders

Group of conditions with disruption in:

• Thinking

• Memory

• Processing

• Problem-solving

Treatment requires compassionate understanding of both the client and their family.

Types of Cognitive Disorders (DSM-5-TR)

Delirium (short-term, reversible)

Mild Neurocognitive Disorder (may or may not progress)

Major Neurocognitive Disorder (Dementia) (progressive, irreversible)

Subtypes of Major & Mild NCD:

• Alzheimer’s Disease (AD): most common, neurodegenerative, gradual impairment of cognitive function

• Parkinson’s disease

• Huntington’s disease

Key Point

• Must distinguish NCD from other mental health disorders.

• Example: Depression in older adults can mimic early Alzheimer’s.

Frequently forgetting small things (MD appt? meds taken? car parked where?).

• Safety concerns: med adherence, getting lost, driving/parking.

Mild Dementia

Recognition issues (“Have we met?” “I’m lost; need to get home.” “Are you sure I own a car?”).

• Safety concerns: wandering, elopement, financial/vulnerability risks.

Moderate Dementia

May forget how to talk, walk, swallow, or even breathe.

• Safety concerns: aspiration, immobility, respiratory compromise, total care needs.

Severe Dementia

Restless, babbling, agitation

• Games, puzzles, coloring

• NO television (too much stimuli)

Hyperactive Delirium

Slow, sleepy, low energy.

Hypoactive Delirium

Delirium vs Dementia Types

Hyperactive: restless, babbling, agitation

• Games, puzzles, coloring

• NO television (too much stimuli)

Hypoactive: slow, sleepy, low energy.

Mixed

Unclassified

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Mild: frequently forgetting small things (MD appt? meds taken? car parked where?).

• Safety concerns: med adherence, getting lost, driving/parking.

Moderate: recognition issues (“Have we met?” “I’m lost; need to get home.” “Are you sure I own a car?”).

• Safety concerns: wandering, elopement, financial/vulnerability risks.

Severe: may forget how to talk, walk, swallow, or even breathe.

• Safety concerns: aspiration, immobility, respiratory compromise, total care needs.

loss of memory

amnesia

loss of skilled movements/gestures DESPITE motor function/intent

apraxia

loss of people/object identification

agnosia

loss of language/swallow

aphasia

Delirium Meds: AFTER ADDRESSING underlying DELERIUM causes

Anxiolytics (e.g., benzos)

Antipsychotics

“4 A’s” of Dementia (Alzheimer’s)

Amnesia: loss of memory

Apraxia: loss of ability to execute skilled movements/gestures despite intact motor function and intent

Agnosia: loss of ability to identify people/objects

Aphasia: slide lists “Loss of ability to swallow” (note: classically aphasia = language impairment; the slide’s phrasing emphasizes functional decline including swallowing problems in severe stages).

Previously anosmia (no longer diagnostic due to covid)

Cognitive Disorders Risk Factors

Delirium:

• Physiological changes:

  • Neurologic (Parkinson’s, Huntington’s)

  • Metabolic (hepatic/renal failure, fluid & electrolyte imbalance, nutritional deficiencies)

  • Cardiovascular/respiratory disease

  • Infections (HIV/AIDS)

  • Surgery

  • Substance use/withdrawal

• Other:

  • Older age

  • Multiple comorbidities

  • Severe illness, polypharmacy

  • ICU stays, surgery, aphasia, restraint use, change in environment

Neurocognitive Disorder & Alzheimer’s Disease (AD):

• Advanced age

• Prior head trauma

• Cardiovascular disease

• Lifestyle factors

• Family history of AD (strong genetic link in early-onset familial AD)

Delirium (8) vs NCD/AD (4) Risk Factors

Neurologic (Parkinson’s, Huntington’s)

Metabolic (hepatic/renal failure, fluid & electrolyte imbalance, nutritional deficiencies)

Infections (HIV/AIDS)

Substance use/withdrawal

ICU stays, surgery, aphasia, restraint use, change in environment

Severe illness

Polypharmacy

Mostly males

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Prior head trauma

Lifestyle factors

Family history

Mostly females

Neurologic (Parkinson’s, Huntington’s)

Metabolic (hepatic/renal failure, fluid & electrolyte imbalance, nutritional deficiencies)

Infections (HIV/AIDS)

Substance use/withdrawal

ICU stays, surgery, aphasia, restraint use, change in environment

Severe illness

Polypharmacy

Mostly males

Advanced age

Cardiovascular/respiratory disease

Delirium Risk Factors

Prior head trauma

Lifestyle factors

Family history

Mostly females

Advanced age

Cardiovascular/respiratory disease

NCD/AD Risk Factors

Delirium & NCD/AD Risk Factors

Advanced age

Cardiovascular/respiratory disease

Delirium Risk Factors: PINCH ME

Poorly controlled pain

Infections (e.g., UTI)

Nutrition issues (poor diet, vitamin deficiency)

• No cooking skills

Constipation (under-recognized trigger)

Hydration (dehydration)

Medications (prescribed or illicit)

Endocrine (diabetes, thyroid disorder).

Cognitive Disorders Expected Findings

Delirium & NCD share similarities but differ in onset/course.

Clients with NCD may also develop delirium.

Delirium vs NCD/AD Findings

Rapid (hours–days)

LOC can rapidly fluctuate (SUNDOWNING)

• Morning - Coherent

• Noon-Night - Confused

4 Types (hyper = restless, hypo = quiet, mixed, unclassified)

Rapid personality change

Unstable vital signs

May involve perceptual disturbances

Reversible if diagnosis/treatment prompt

Medical emergency

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Gradual deterioration (months–years)

LOC usually unchanged or gradual

• 3 Days - Coherent

• 4 Days - Confused

Gradual personality change

Stable vital signs

Common: Restlessness, agitation, sundowning

Irreversible and progressive

Gradual deterioration (months–years)

LOC usually unchanged or gradual

• 3 Days - Coherent

• 4 Days - Confused

Gradual personality change

Stable vital signs

Common: Restlessness, agitation, sundowning

Irreversible and progressive

NCD/AD Findings

Rapid (hours–days)

LOC can rapidly fluctuate (SUNDOWNING)

• Morning - Coherent

• Noon-Night - Confused

4 Types (hyper = restless, hypo = quiet, mixed, unclassified)

Rapid personality change

Unstable vital signs

May involve perceptual disturbances

Reversible if diagnosis/treatment prompt

Medical emergency

Delirium Findings

Fluctuating Course

More coherent in the morning, confusion/hallucinations in afternoon (“sundowning”)

Can help differentiate from dementia’s more consistent/enduring confusion.

• Delirium - Think fast turnaround, clear during day, confused at night

• Dementia (NCD) - Think slow turnaround, 3 days of clarity, 4 days of confusion

Cognitive Disorders Defense Mechanisms

Denial: Client/family refuse to believe memory loss is happening, even when obvious.

Confabulation: Client makes up stories about events they don’t remember (unconscious attempt to protect self-esteem, not intentional lying).

Perseveration: Client repeats phrases/behaviors instead of answering questions (protects self-esteem when memory fails).

Cognitive Disorders Diagnostic Procedures

No specific test → definitive diagnosis only at autopsy

Testing done to rule out other pathologies:

• Chest/head x-rays

• EEG (electroencephalography)

• ECG (electrocardiography)

• Liver function studies

• Thyroid function tests

• Neuroimaging (CT, PET)

• Urinalysis

• Blood electrolytes

• Folate & vitamin B12 levels

• Vision & hearing tests

• Lumbar puncture

Cognitive Disorders Screening & Assessment Tools

For Delirium

• Confusion Assessment Method (CAM)

• Neelon-Champagne (NEECHAM) Confusion Scale

For Dementia/Neurocognitive Disorders

• Functional Dementia Scale (self-care, memory loss, mood, danger to self/others)

• Brief Interview for Mental Status (BIMS) – long-term care settings

• Mini-Mental Status Examination (MMSE)

• Functional Assessment Screening Tool (FAST)

• Global Deterioration Scale

• Blessed Dementia Scale (uses info from family/secondary source)

A nurse is performing an admission assessment for a client who has delirium related to an acute urinary tract infection. Which of the following findings should the nurse expect?

Select all that apply.

a

History of gradual memory loss

b

Family report of personality changes

c

Hallucinations

d

Unaltered level of consciousness

e

Restlessness

b Family report of personality changes

c Hallucinations

e Restlessness

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The client who has delirium can experience memory loss with sudden rather than gradual onset.

The client who has delirium is expected to have an altered level of consciousness that can rapidly fluctuate.

Cognitive Disorders Nursing Care

Prevention/management: minimize risk factors, promote early detection (timely recognition = essential).

Nurse self-awareness: manage frustration, anger, or fear when caring for progressive decline.

Focus: protect from injury while promoting dignity and quality of life.

Safe/Therapeutic Environment

• Assess risk for falls/wandering.

• Place client near nurses’ station.

• Provide low-level visual/auditory stimuli.

• Well-lit environment, minimize contrasts/shadows.

• Room with windows for time orientation.

• Identification bracelet; use monitors/bed alarms PRN.

• Restraints = last resort.

• Cautious PRN meds for agitation/anxiety.

• Lower bed, assess risk for injury.

Cognitive Support

• Use memory aids: clocks, calendars, photos, memorabilia, familiar objects.

• Reorient as needed.

• Maintain consistent routine and caregivers.

• Remove mirrors (reduce fear/agitation).

• Encourage daily physical activity.

• Ensure bathroom has adequate lighting at night.

Physical Needs

• Monitor neurologic status.

• Identify physiologic disturbances contributing to delirium.

• Assess skin integrity (risk: poor nutrition, immobility, incontinence).

• Monitor vital signs (tachycardia, BP changes, diaphoresis, dilated pupils may indicate delirium).

• Promote sleep and comfort (nonverbal indicators matter).

• Provide eyeglasses/hearing aids if needed.

• Ensure food/fluid intake.

• Monitor lab results (electrolyte imbalances can cause delirium).

Communication

• Calm, reassuring tone.

• Positive phrasing (do not argue or question hallucinations/delusions).

• Reinforce reality, orientation to time/place/person.

• Introduce self with each contact.

• Eye contact; short, simple sentences; one item of info at a time.

• Encourage reminiscing about happy/familiar events.

• Break instructions into short segments.

• Limit choices when dressing/eating.

• Reduce decision-making/abstract thinking demands (avoid frustration).

• Avoid confrontation.

• Approach slowly, from the front; use client’s name.

• Encourage family visits as appropriate.

Delirium Medications (AA)

Use caution with PRN meds for agitation/anxiety

Always evaluate if medications are causing or worsening

Medications may be underlying cause → monitor for reactions.

Management:

• Treat underlying disorder.

• Antipsychotics or antianxiety meds may be prescribed.

Cholinesterase Inhibitors Actions / Use

Inhibits acetylcholine breakdown → Increases acetylcholine

• Improves memory, thinking, learning

• Slows cognitive decline

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Mild to moderate Alzheimer’s disease (AD).

Cholinesterase Inhibitors Complications / Contraindications

GI: Nausea, vomiting, diarrhea → monitor closely, promote adequate fluid intake, titrate dose.

Bradycardia, syncope → orthostatic hypotension

• Teach family to monitor pulse at home.

• Screen for underlying heart disease.

Bronchoconstriction

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Contraindication: GI Bleeding

Use cautiously with: Asthma, obstructive pulmonary disorders (bronchoconstriction risk)

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the NVD uses CHOLesky factorization to prevent SYNCOPE/FAINTING in ASTHMA patients with SLOW HEART and PULMONARY prosthetics

the NVD uses CHOLesky factorization to prevent SYNCOPE/FAINTING in ASTHMA patients with SLOW HEART and PULMONARY prosthetics

Cholinesterase Inhibitors Complications / Contraindications

GI: Nausea, vomiting, diarrhea → monitor closely, promote adequate fluid intake, titrate dose.

Bradycardia, syncope → orthostatic hypotension

• Teach family to monitor pulse at home.

• Screen for underlying heart disease.

Bronchoconstriction

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Contraindication: GI Bleeding

Use cautiously with: Asthma, obstructive pulmonary disorders (bronchoconstriction risk)

Cholinesterase Inhibitors Interactions / Admin

NSAIDs (e.g., aspirin): ↑ GI bleeding risk → monitor NSAID use and GI symptoms.

Antihistamines, tricyclic antidepressants, conventional antipsychotics, anticholinergics: ↓ therapeutic effects

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Start low dose → gradually increase until therapeutic or adverse effects appear.

• Educate client/family about adverse effects.

Taper medication when discontinuing to avoid rapid progression.

Monitor swallowing ability (available in tablets, oral solutions, orally disintegrating tablet for donepezil).

Administration:

• Donepezil: once daily at bedtime (long half-life).

• Others: usually twice daily.

• Rivastigmine: oral form or patch (apply daily; take with food to ↓ GI upset).

Cholinesterase Inhibitors Meds: she DONNED an indian iron CHOLI from the RIVer GALA MINE

Donepezil

Rivastigmine

Galantamine

When should Donepezil be taken?

At night due to long half-life

N-methyl-D-aspartate (NMDA)

An excitatory glutamate receptor

• Requires glutamate binding and calcium ion charges

• Involved in learning, memory, and other vital functions.

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Overactivation of receptors can lead to cell damage and is linked to neurological disorders, particularly in Alzheimer’s patients.

NMDA Receptor Antagonist Action / Use

Blocks calcium entry and glutamate activation into nerve cells

• Slows brain-cell death (neuroprotection)

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Moderate to severe Alzheimer’s disease (AD).

Mild to moderate vascular dementia

NMDA Receptor Antagonist Complications / Contraindications

Dizziness, headache, confusion, constipation.

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Pregnancy/breastfeeding, epilepsy/seizure disorder, severe hepatic/renal impairment.

Main Contraindication: Renal failure

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CONSTIPATED CHADs NEVER MAKE DUMPS AVAILABLE due to KIDNEY FAILURE

CONSTIPATED CHADs NEVER MAKE DUMPS AVAILABLE due to KIDNEY FAILURE

NMDA Receptor Antagonist Complications

• Dizziness, headache, confusion, constipation.

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Pregnancy/breastfeeding, epilepsy/seizure disorder, severe hepatic/renal impairment.

Main Contraindication: Renal failure

NMDA Receptor Antagonist Interactions / Admin

May be used with a cholinesterase inhibitor.

Give with or without food.

Report any worsening confusion, dizziness, or headache to the provider.

Encourage safe ambulation if dizziness occurs, and assess for changes in bowel habits

Antacids and other drugs that increase urine pH can elevate drug levels, increasing toxicity risk.

NMDA Receptor Antagonist Meds: MASTURBATION (euphemism) does not clear my bowels when I can NEVER MAKE DUMPS AVAILABLE

Memantime

MASTURBATION (euphemism) does not clear my bowels when I can NEVER MAKE DUMPS AVAILABLE

NMDA Receptor Antagonist Meds

• Memantime

NCD/AD Medications: SRA members with DEMENTIA need a CNA for gun control

Cholinesterase Inhibitors

• Examples: Donepezil, Rivastigmine, Galantamine

• Action: ↑ acetylcholine by inhibiting breakdown → improves self-care ability, slows cognitive decline in mild–moderate Alzheimer’s.

Adverse Effects

• GI: Nausea, vomiting, diarrhea → monitor closely, promote adequate fluid intake, titrate dose.

• Bradycardia, syncope → teach family to monitor pulse at home.

• Screen for underlying heart disease.

Contraindications/Precautions

• Use cautiously with:

  • Asthma, obstructive pulmonary disorders (bronchoconstriction risk).

Interactions

• NSAIDs (e.g., aspirin): ↑ GI bleeding risk → monitor NSAID use and GI symptoms.

• Antihistamines, tricyclic antidepressants, conventional antipsychotics: ↓ therapeutic effects of donepezil → avoid cholinergic-blocking drugs.

Nursing Administration

• Start low dose → gradually increase until therapeutic or adverse effects appear.

• Educate client/family about adverse effects.

• Taper medication when discontinuing to avoid rapid progression.

• Monitor swallowing ability (available in tablets, oral solutions, orally disintegrating tablet for donepezil).

• Administration:

  • Donepezil: once daily at bedtime (long half-life).

  • Other cholinesterase inhibitors: usually twice daily.

  • Rivastigmine: oral form or patch (apply daily; take with food to ↓ GI upset).

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NMDA Receptor Antagonist

Memantine

• Blocks calcium entry into nerve cells → slows brain-cell death.

• Approved for moderate to severe Alzheimer’s disease (AD).

Nursing Actions

• May be used with a cholinesterase inhibitor.

• Give with or without food.

• Monitor adverse effects: dizziness, headache, confusion, constipation.

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Other Medications

• SSRIs: for depression.

• Antianxiety meds: for agitation.

• Antipsychotics: for hallucinations/delusions (last resort; many adverse effects).

SRA members with DEMENTIA need a CNA for gun control

NCD/AD Medications

• SSRIs: for depression.

• Antianxiety meds: for agitation.

• Cholinesterase Inhibitors

• NMDA Receptor Antagonist

• Antipsychotics: for hallucinations/delusions (last resort; many adverse effects).

Cholinesterase Inhibitors

Examples: Donepezil, Rivastigmine, Galantamine

Action: ↑ acetylcholine by inhibiting breakdown → improves self-care ability, slows cognitive decline in mild–moderate Alzheimer’s.

Adverse Effects

• GI: Nausea, vomiting, diarrhea → monitor closely, promote adequate fluid intake, titrate dose.

• Bradycardia, syncope → teach family to monitor pulse at home.

• Screen for underlying heart disease.

Contraindications/Precautions

• Use cautiously with:

  • Asthma, obstructive pulmonary disorders (bronchoconstriction risk).

Interactions

• NSAIDs (e.g., aspirin): ↑ GI bleeding risk → monitor NSAID use and GI symptoms.

• Antihistamines, tricyclic antidepressants, conventional antipsychotics: ↓ therapeutic effects of donepezil → avoid cholinergic-blocking drugs.

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Nursing Administration

• Start low dose → gradually increase until therapeutic or adverse effects appear.

• Educate client/family about adverse effects.

• Taper medication when discontinuing to avoid rapid progression.

• Monitor swallowing ability (available in tablets, oral solutions, orally disintegrating tablet for donepezil).

• Administration:

  • Donepezil: once daily at bedtime (long half-life).

  • Other cholinesterase inhibitors: usually twice daily.

  • Rivastigmine: oral form or patch (apply daily; take with food to ↓ GI upset).

NMDA Receptor Antagonist

Memantine

• Blocks calcium entry into nerve cells → slows brain-cell death.

• Approved for moderate to severe Alzheimer’s disease (AD).

Nursing Actions

• May be used with a cholinesterase inhibitor.

• Give with or without food.

• Monitor adverse effects: dizziness, headache, confusion, constipation.

A nurse is caring for a client who has early stage Alzheimer’s disease and a new prescription for donepezil. The nurse should include which of the following statements when teaching the client about the medication?

a

“You should avoid taking over-the-counter acetaminophen while on donepezil.”

b

“You should take this medication before going to bed at the end of the day.”

c

“You will be screened for underlying kidney disease prior to starting donepezil.”

d

“You will be screened for underlying kidney disease prior to starting donepezil.”

b “You should take this medication before going to bed at the end of the day.”

Donepezil should be taken at the end of the day or before bed due to tis long half-life

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Tell the client to avoid NSAIDs, rather than acetaminophen, due to risk for gastrointestinal bleeding.

Clients should be screened for underlying heart and pulmonary disease, rather than kidney disease, prior to treatment.

Cognitive Disorders Alternative/Complementary Therapies

Alternative/Complementary Therapies

• Some vitamins/herbals under investigation.

  • Currently no evidence they are effective.

Client Education Care After Discharge

• Educate family/caregivers about illness, care methods, home adaptations.

• Ensure safe home environment.

Key Questions to Ask

• Will client wander if doors left unlocked?

• Can client remember address and name?

• Does client harm others when allowed to wander?

Home Safety Measures

• Remove scatter rugs.

• Door locks that are not easily opened.

• Lock/tune water heater thermostat to safe level.

• Good lighting, especially on stairs.

• Install stair handrails, mark step edges with colored tape.

• Place mattresses on floor (prevent falls).

• Remove clutter, keep walkways clear.

• Secure electrical cords.

• Store cleaning supplies in locked cupboards.

• Install grab bars in bathrooms.

• Allow safe pacing/wandering.

Support for Caregivers

• Encourage seeking legal counsel for advanced directives, guardianship, or durable power of attorney for health care.

• Determine teaching needs of client & family as cognitive decline progresses.

• Review available resources:

  • Long-term care options.

  • Home care/community resources (can help client remain at home vs. facility).

• Provide support for caregivers:

  • Ask for help from friends/family.

  • Use respite care and support groups.

• Encourage caregivers to practice self-care and take things one day at a time.

A nurse in a long-term care facility is caring for a client who has major neurocognitive disorder and attempts to wander out of the building. The client states, “I have to get home.” Which of the following statements should the nurse make?

a

“You have forgotten that this is your home.”

b

“You cannot go outside without a staff member.”

c

“Why would you want to leave? Aren’t you happy with your care?”

d

“I am your nurse. Let’s walk together to your room.”

d “I am your nurse. Let’s walk together to your room.”

When the nurse recognizes the client is attempting to wander out of the building, the nurse should introduce oneself with each new interaction and to promote reality in a calm, reassuring manner.

A home health nurse is making a visit to a client who has Alzheimer’s Disease to assess the home for safety. Which of the following suggestions should the nurse make to decrease the client’s risk for injury?

a

Install extra locks at the top of exit doors.

b

Place rugs over electrical cords.

c

Put cleaning supplies on the top of a shelf.

d

Place the client’s mattress on the floor.

e

Install light fixtures above stairs.

a Install extra locks at the top of exit doors.

d Place the client’s mattress on the floor.

e Install light fixtures above stairs.

When taking action, the nurse should suggest the following to decrease the client’s risk for injury in the home placing door locks up high where they are difficult to reach can prevent exiting the home and wandering outside, placing the client’s mattress on the floor to reduce the risk for falls out of the bed Instruct the family to ensure there is adequate lighting around the stairs to reduce the risk for falls.

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Cleaning supplies should be placed in locked cupboards. Marking the supplies with colored tape does not prevent the client’s access to hazardous materials.

A nurse is making a home visit to a client who is in the late stage of Alzheimer’s Disease. The client’s partner, who is the primary caregiver, wishes to discuss concerns about the client’s nutrition and the stress of providing care. Which of the following actions should the nurse take?

a

Verify that a current power of attorney document is on file.

b

Instruct the client’s partner to offer finger foods to increase oral intake.

c

Provide information on resources for respite care.

d

Schedule the client for placement of an enteral feeding tube.

c Provide information on resources for respite care.