Neurocognitive Disorders: Delirium and Dementia

NEUROCOGNITIVE DISORDERS: DELIRIUM AND DEMENTIA

LEARNING OUTCOMES

  • Differentiate between delirium and dementia.

  • Define neurocognitive disorders.

  • List the most common forms of dementia.

  • Identify common causes of delirium.

  • Describe effective treatments for each condition.

NEUROCOGNITIVE DISORDERS

  • Definition: Clinically significant deficits in cognition or memory that are significant enough to disrupt daily functioning.

  • Requirements:

    • Must reflect a major change from an individual’s original cognitive baselines.

    • Can affect one’s ability to think, remember, or make sound decisions temporarily or permanently.

  • Includes both delirium and dementia.

    • Delirium: Characterized by sudden onset, typically due to an underlying organic issue.

    • Dementia: Characterized by a gradual onset and is a progressive disease.

DELIRIUM

  • Nature: Acute reaction to underlying physiological or psychological stress that manifests rapidly and varies throughout the day.

  • Common Situations:

    • Often develops after surgery or hospitalization.

  • Common Causes:

    • Dehydration

    • Hypoxia

    • Infection (e.g., UTI and fever)

    • Medication mismanagement

    • Depression and emotional stress

    • Alcohol use and withdrawal

    • Nocturnal delirium - termed “Sundowning”.

  • Symptoms:

    • Confusion and memory impairment.

    • Hallucinations and/or delusions.

    • Emotional instability and agitation.

    • Sleep issues.

  • Prevalence: Very common among the elderly, with 29-64% of patients in hospitals experiencing delirium.

  • Implications: Increases mortality and morbidity rates.

  • Treatment Focus:

    • Identify and treat the underlying cause.

    • Control agitation and prevent further complications or injury.

DEMENTIA

  • Definition: Gradual loss of cognitive functioning, affecting memory, language, executive function, and attention, while the person remains fully alert.

    • Classified as a neurocognitive disorder by DSM-V.

  • Characteristics:

    • Considered irreversible, not a normative aspect of aging.

  • Classification: Mild vs. Major Neurocognitive Disorder.

  • Domains Measured:

    • Complex attention.

    • Executive function (planning and organizing).

    • Learning and memory.

    • Language.

    • Perceptual motor skills.

    • Social cognition.

TYPES OF DEMENTIA

  • Primary Degenerative Dementias:

    • Alzheimer’s Disease

    • Lewy-Body Dementia: Includes parkinsonian symptoms and hallucinations.

  • Secondary Dementias:

    • Vascular Dementia (associated with strokes).

    • HIV-associated Dementia

    • Head injury induced

    • Substance-induced (drug/alcohol).

  • Causative Factors: Depression in the elderly could be misdiagnosed as dementia.

  • Nature of Damage:

    • Generally irreversible with no known cure.

    • Damage occurs at the cellular level with the following important markers:

    • Amyloid plaques seen in Alzheimer’s Disease.

    • Lewy-bodies in Lewy Body Dementia.

ALZHEIMER’S DISEASE

  • Prevalence: Accounts for 60-80% of dementia cases; the exact cause remains unknown.

    • About 11.3% of Americans aged > 65 years are affected.

    • It is the 5th leading cause of death in this demographic.

    • Common sequelae include aspiration, infections, falls, immobility, malnutrition, and dysphagia.

  • Phases of Disease:

    • Preclinical

    • Mild impairment

    • Dementia: classified further into mild, moderate, and severe.

  • Diagnosis: Primarily through cognitive tests, with tools like PET scans or lumbar punctures for early detection.

  • Management:

    • Progressive and irreversible with medications being developed to slow progression in some patients.

    • Cholinesterase inhibitors: Effective in about half of early-stage patients (e.g., Donepezil (Aricept)).

    • Supportive care, family care planning, and mood management medications.

LEWY-BODY DEMENTIA

  • Demographic: More prevalent in men.

  • Diagnosis: Based on symptom presentation.

  • Symptoms:

    • Delusions and hallucinations.

    • Parkinsonian movements.

  • Challenges: Extremely sensitive to antipsychotics, risking neuroleptic malignant syndrome and delirium.

  • Few effective medication options for treatment.

DIFFERENTIATING DELIRIUM AND DEMENTIA

  • Misdiagnosis Risk: Confused or agitated patients may often be misdiagnosed due to similar symptoms.

  • Best Practices:

    • Conduct thorough medical workups for any patient presenting with confusion.

    • Important assessments include:

    • Labs and vitals.

    • Medication reconciliation to rule out medical issues.

    • Note that individuals with dementia can also experience episodes of delirium.

NURSING CARE FOR DEMENTIA PATIENTS

  • Therapeutic Use of Self: Strive for calm and patient interactions.

  • Patient Interaction Guidelines:

    • Remain calm and avoid arguing with patients.

    • Redirect inappropriate behaviors gently.

    • Use simple and clear communication.

    • Avoid overwhelming patients with options.

    • Allow adequate time for responses and provide emotional support (only using touch when appropriate).

ENHANCING PATIENT ENVIRONMENT FOR DEMENTIA

  • Ensure specialized stimulation: Engage them through conversations where possible.

  • Utilize nostalgic elements:

    • Old photographs

    • Music therapy

    • Familiar scents or mementos.

  • Ensure basic needs are met:

    • Adequate nutrition and hydration.

MANAGING DEMENTIA: WANDERING AND AGITATION

  • Preventing Wandering:

    • Identify underlying issues (e.g., hunger, thirst, need for restrooms).

    • Maintain safe environments and structured routines.

    • Minimize unnecessary stimulation (utilizing tools like pagers and radios).

    • Turn off distractions (lights, TVs) simultaneously every night.

    • Implement calming sounds (nostalgic music) in nightly routines.

  • Managing Agitation:

    • Remain calm and redirect where necessary; sitters may be required.

    • Use antipsychotics and antianxiety medications as needed (PRN).

    • Avoid using restraints unless as a last resort, for both physical and chemical interventions.

CASE STUDIES

RECOGNIZING CUES

  • Case Study of Mrs. Carter (78-year-old widow): potential signs of neurocognitive disorder:

    • Episodes of paranoia.

    • Normal function and self-care despite behavioral changes.

    • Notable weight loss and empty fridge.

    • Agitation experienced in public spaces.

ANALYZING CUES

  • Distinctions made between findings consistent with delirium or dementia:

    • Delirium: Examples include agitation, fever-induced confusion, dehydration.

    • Dementia: Examples include gradual memory loss trends.

PRIORITIZING HYPOTHESES

  • During intake assessment, evidence requiring immediate priority:

    • A high temperature of 39.2°C oral must be addressed urgently.

GENERATE SOLUTIONS

  • Care Plan Goals for Mrs. Carter:

    • Weight Gain: Provide and insist on complete meals.

    • Sleep Improvements: Keep favorite TV shows on during the night and schedule nighttime environments.

    • Reducing Agitation: Implement calming redirection and avoid behavioral reprimands.

TAKE ACTION

  • Appropriate nurse response to agitation during care:

    • Maintain calm demeanor and redirect the patient before opting for medication or restraints.

EVALUATE OUTCOMES

  • Discuss correct understanding and implications of Alzheimer's diagnosis.

    • Clarify that while confusion may be attributed to infection, Alzheimer’s disease is progressive and irreversible, and memory will not return to normal post-treatment.

REFERENCES

  • Gorman, L., & Anwar, R. (2022). Mental health nursing (6th ed.). Philadelphia, PA: F.A. Davis.