NEUROCOGNITIVE DISORDERS

NEUROCOGNITIVE DISORDERS

LEARNING OBJECTIVES

• Impact of Neurocognitive Disorders: Describe how neurocognitive disorders affect a client’s overall health.

• Epidemiological Factors: Explore the epidemiological and etiological risk factors that contribute to clients experiencing neurocognitive disorders.

• Clinical Presentation: Differentiate the clinical presentation of clients with neurocognitive disorders.

• Nursing Role: Explore the nurse's role when caring for clients with neurocognitive disorders.

• Nursing Process Application: Apply the nursing process through clinical judgment functions while providing care to clients with neurocognitive disorders.

TYPES OF NEUROCOGNITIVE DISORDERS

• Delirium:
    - Definition: Short-term and episodic disturbance characterized by impaired attention and cognitive disturbance.

• Dementia:
    - Definition: Cognitive decline with multiple types affecting everyday functioning.

DELIRIUM

• Definition: A disturbance in attention that develops over a short period, along with additional cognitive disturbances.

DEMENTIA AND MAJOR NEUROCOGNITIVE DISORDERS

• Dementia: Frequently used synonymously with neurocognitive disorders, defined by the American Psychiatric Association (APA) as significant cognitive decline in one or more cognitive domains (e.g., complex attention, executive function, learning and memory, language, perceptual-motor, social cognition).

• Criteria:
    - Deficits must interfere with independence in daily activities and cannot be better explained by delirium or another disorder. (APA, 2013)

DELIRIUM COMPARED TO DEMENTIA

Factors Comparison (1 of 2)

Factors Comparison (2 of 2)

NEUROCOGNITIVE DISORDERS – DSM-5 CATEGORIES

1. Alzheimer’s disease

2. Frontotemporal lobar degeneration (formerly known as Pick’s disease)

3. Lewy body disease

4. Vascular disease

5. Traumatic brain injury (APA, 2013)

6. Substance/medication use

7. HIV infection

8. Prion disease

9. Parkinson’s disease

10. Huntington’s disease

11. Other medical conditions/multiple etiologies/unspecified (APA, 2013)

ETIOLOGY

DELIRIUM – ETIOLOGY

• Caused by: Intoxication or withdrawal from substances such as:
    - Alcohol, cannabis, phencyclidine, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, amphetamines, cocaine.

• Other factors:
    - Drugs: lithium, levodopa, steroids, digitalis, antidepressants, benzodiazepines
    - CNS depressants, trauma, stress, and sleep deprivation.
    - Emotional disturbances.

DELIRIUM – COMORBIDITIES

• Risk factors include dehydration, electrolyte imbalances, infections, hepatic encephalopathy, metabolic disorders, tumors, and Vitamin B12 deficiency (Mayo Clinic, 2021b).

ALZHEIMER'S DISEASE – ETIOLOGY (1 of 2)

• Presence of Amyloid Plaques: Characteristic of Alzheimer's disease.

• Age: The strongest risk factor for developing Alzheimer's.

• Demographics: More prevalent in women.

ALZHEIMER'S DISEASE – ETIOLOGY (2 of 2)

• At-risk Populations: Include individuals with:
    - Traumatic brain injury
    - Down syndrome
    - Vascular disease.

VASCULAR DISEASE DEMENTIA – ETIOLOGY

• Deficits associated with blood vessels, hypertension, and cerebrovascular “events.”

• Risk Factors: Increases exponentially after age 65.

LEWY BODY DEMENTIA – ETIOLOGY

• Characterized by the presence of Lewy bodies in the brain, leading to symptoms such as:
    - Increased risk of falls and injury
    - Memory loss
    - Parkinson's disease-like signs
    - Autonomic dysfunction
    - Sleep issues.

FRONTOTEMPORAL LOBE DEMENTIA – ETIOLOGY

• Family History: 40% have a family history with potential genetic mutations:
    - Gene coding for tau (MAPT)
    - Granulin gene (GRN)
    - C9ORF72 gene.

OTHER DEMENTIAS – ETIOLOGY

• Causes include:
    - TBI: Injury to the brain.
    - HIV: Infection with the virus.
    - Prion diseases: Generally linked to eating contaminated meat.
    - Genetic Factors: As seen in Huntington’s and Parkinson’s disease.

CLINICAL MANIFESTATIONS

DEMENTIA

• Cognitive Domains Impaired:
    - Executive function
    - Complex attention
    - Learning/memory
    - Perceptual/motor
    - Social cognition.

DEMENTIA – EXECUTIVE FUNCTION

• Major Manifestations:
    - Stops complex projects, needs assistance in planning and decision making.

• Mild Manifestations:
    - Increased effort needed for multistage tasks; difficulty multitasking.

DEMENTIA – COMPLEX ATTENTION

• Major Manifestations:
    - Difficulty in distracting environments, needs simple and restricted input; slower processing.

• Mild Manifestations:
    - Normal tasks take longer; needs double-checking, better without distractions.

DEMENTIA – LEARNING/MEMORY

• Major Manifestations:
    - Repeats self in conversation; cannot track short lists when shopping.

• Mild Manifestations:
    - Difficulty recalling recent events; needs reminders and lists. Semantic, autobiographical, and implicit memory relatively intact.

DEMENTIA – LANGUAGE

• Major Manifestations:
    - Significant difficulties with expressive or receptive language; pronoun use instead of names.

• Mild Manifestations:
    - Noticeable word-finding difficulties; grammatical errors.

DEMENTIA – PERCEPTUAL/MOTOR

• Major Manifestations:
    - Significant difficulties with familiar activities; confusion increases at dusk.

• Mild Manifestations:
    - Increased reliance on maps and notes; less precise in spatial tasks.

DEMENTIA – SOCIAL COGNITION

• Major Manifestations:
    - Insensitivity to social norms; unsafe decision-making.

• Mild Manifestations:
    - Subtle behavioral changes; decreased empathy and increased restlessness.

ALZHEIMER'S DISEASE – DSM-5 CRITERIA

• Indications: Insidious onset, gradual progression, at least two cognitive domains must be impaired.
    - Major: Required genetic mutation and evidence of declined cognition across multiple domains.
    - Mild: Genetic mutation presence with evidence of memory or learning decline.

ALZHEIMER'S – MANIFESTATIONS BY STAGE

1. Mild:
      - Not obvious; friends/family notice subtle changes.
      - Misplacement of objects, forget names, and difficulty planning.

2. Moderate:
      - Confusion regarding place and time; needed assistance in daily routines; confabulation occurs.

3. Severe:
      - Difficulty with communication and environmental responses; atypical behaviors manifest.

FRONTOTEMPORAL LOBAR DEGENERATION DEMENTIA – DSM-5 CRITERIA

• Insidious onset and gradual progression with three behavioral variants and a decline in social cognition or executive function:
    - Disinhibition, apathy, inertia, loss of empathy, compulsive/ritualistic behavior.

LEWY BODY DEMENTIA

• Core Diagnostic Features:
    - Fluctuating cognition, recurrent visual hallucinations, parkinsonism features, severe neuroleptic sensitivity.
    - Men: rapid eye movement sleep behavior as initial sign; women: hallucinations.

VASCULAR DISEASE DEMENTIA – MANIFESTATIONS

• Cognitive Declines:
    - Decreased processing speed and impaired executive functions.

TBI – MANIFESTATIONS

• Loss of consciousness, posttraumatic amnesia, disorientation, confusion, neurological signs.

THE CARE TEAM

THE CARE TEAM MEMBERS

• Providers: Include psychologists, nurses, assistive personnel, recreational therapists, adult day care providers, and emergency response personnel.

• Therapists: Such as speech, music, physical, and occupational therapists.

• Social workers and hospice staff.

NURSE’S ROLE

Attributes of Nursing Care (1 of 2)

• Equitable and Sensitive Care: Emphasizes knowledge, compassion, empathy, and self-awareness.

Attributes of Nursing Care (2 of 2)

• Advocacy: Ensuring the least restrictive environment and safety (both at home and inpatient).

• Teaching: Involvement of family and caregivers in care processes.

• Therapeutic Presence: Use of self, compassion, and active listening.

• Communication: Employ calm tones, reinforce reality, use short phrases, and limit choices.

SAFETY MEASURES – HOME

• Ensure appropriate supervision according to illness stage.

• Potential modifications for fall prevention, burn protection, and wandering prevention (e.g., tracking devices).

• Improve environmental safety through securing locks, removing hazards, and installing safety rails.

SAFETY MEASURES – INPATIENT

• Ensure accessibility to hearing aids; minimize mirrors; install grab bars and railings for balance.

• Maintain well-lit areas to reduce disorientation; use identification bracelets.

THE NURSING PROCESS: ASSESSMENT

• Assessment Steps:
    1. Recognize Cues: Monitor mood, safety, cognition, communication, physical symptoms, and mobility.
    2. Focused Assessment Cues: Involves assessing signs of delirium and dementia, and monitoring the client’s safety.

LAB/DIAGNOSTIC TESTS

COMMON TESTS (1 of 2)

• Delirium Assessments: Chemistry panel.

• Alzheimer's Assessments:
    - Positron emission tomography (PET) for amyloid plaques.
    - Mini-Mental State Examination (MMSE): 22-26 = mild, 18-20 = moderate, 0-10 = severe.

COMMON TESTS (2 of 2)

• Frontal Temporal Lobar Assessments: CT/MRI for structural imaging.

• HIV Testing: Laboratory detection of the virus.

TBI DIAGNOSIS

• Imaging: CT or MRI to assess brain injury.

• Severity Ratings for TBI:
    - Mild TBI: Loss of consciousness less than 30 minutes.
    - Moderate TBI: 30 minutes to 24 hours.
    - Severe TBI: More than 24 hours.

DIFFERENTIATING THE 3 D’S (1 of 3)

DIFFERENTIATING THE 3 D’S (2 of 3)

DIFFERENTIATING THE 3 D’S (3 of 3)

THE NURSING PROCESS: ANALYZE CUES

Assessment Framework

1. Recognize cues

2. Analyze cues and prioritize hypotheses

3. Generate solutions

THE NURSING PROCESS: PLANNING

• Steps in Planning:
    - Patient-centered.
    - Involve client and family in the planning process,
    - Connect to resources (e.g., Alzheimer’s Association, relevant caregiving groups).

THE NURSING PROCESS: IMPLEMENTATION

Nonpharmacologic Actions

• Focus: Education/support groups, personal care assistance, reminiscence therapy, craniosacral massage, and herbal therapies.

Personal Care Considerations

• Clothing adjustments for ease of use

• Food and fluid monitoring, especially for nutrition and safety considerations in feeding.

DIET

• MIND Diet: Combination of DASH and Mediterranean diets shown to delay progression of neurodegenerative diseases.

Pharmacologic Actions

• For Delirium: Treat underlying causes, possibly use benzodiazepines for delirium tremens.

• For Alzheimer's: Cholinesterase inhibitors (e.g., donepezil, rivastigmine) to manage symptoms and drugs like aducanumab for disease progression.

• For Other Dementias: Medications targeting specific symptoms or causes.

EVALUATE OUTCOMES

• Assess cognitive and behavioral changes frequently.

• Evaluate caregiver strain and suggest respite care.

• Monitor for medication adherence and effectiveness.

APPENDIX 1: FRONTOTEMPORAL LOBE DEMENTIA

Brain Function Overview

• Frontal Lobe: Controls speech/motor functions.

• Temporal Lobe: Associated with memory/emotional function.

• Parietal Lobe: Involved in sensory perceptions.

• Occipital Lobe: In charge of vision.

• Cerebellum: Maintains balance and coordination.

• Brain Stem: Governs autonomic functions.

Impact of Frontotemporal Dementia on Brain Structures

• Frontal Lobe: Lack of focus, irritability, and language difficulty.

• Temporal Lobe: Affecting short and long-term memory.

• Occupational Lobe: Blind spots and blurred vision.