Neurocognitive Disorders Summary

Cognitive Domains

  • Complex attention: Focus duration, sustained attention, selective attention, alternating attention, and divided attention. Includes the ability to maintain focus over time, selectively attend to relevant stimuli, switch attention between tasks, and divide attention between multiple tasks simultaneously.

  • Executive functioning: Planning and execution, working memory, cognitive flexibility, inhibition, and decision-making. Encompasses the higher-order cognitive processes responsible for goal-directed behavior, including planning, problem-solving, and self-regulation.

  • Learning and memory: Immediate memory, recent memory, remote memory, and implicit memory. Involves the encoding, storage, and retrieval of information, including factual knowledge, personal experiences, and motor skills.

  • Language: Verbal and non-verbal communication, expressive language, receptive language, and speech fluency. Includes the ability to understand and produce spoken and written language, as well as non-verbal cues such as gestures and facial expressions.

  • Social cognition: Social awareness, anxiety, empathy, and theory of mind. Encompasses the cognitive processes involved in understanding and responding to social situations, including recognizing emotions, interpreting social cues, and understanding others' perspectives.

  • Perceptual and motor ability: Spatial and sensory awareness, visual perception, motor coordination, and sensory discrimination. Involves the ability to perceive and interpret sensory information, coordinate movements, and interact with the physical environment.

Neurocognitive Disorder Categories

  • Delirium

  • Mild Neurocognitive Disorder

  • Major Neurocognitive Disorder

Delirium

  • Secondary to another medical condition or substance use. Often arises in the context of underlying medical illnesses, such as infections, metabolic disturbances, or neurological disorders, or as a consequence of substance intoxication or withdrawal.

  • Acute disturbance of consciousness and cognition. Characterized by a sudden onset and fluctuating course, with disturbances in attention, awareness, and orientation to the environment.

  • Can be a medical emergency, especially in older adults. Due to its potential to cause significant morbidity and mortality, particularly in vulnerable populations such as older adults and individuals with pre-existing cognitive impairment.

  • Treatment: address underlying cause, manage symptoms, supportive care. Involves identifying and treating the underlying medical condition or substance use issue, as well as providing supportive care to manage symptoms and promote recovery.

  • Causes:

    • Medications, intoxication/withdrawal (alcohol, cannabis, opioids, etc.). Both prescription and over-the-counter medications can contribute to delirium, as can substance intoxication or withdrawal from alcohol, cannabis, opioids, and other drugs.

    • Drugs (lithium, steroids, antidepressants, etc.). Certain medications, such as lithium, steroids, and antidepressants, have been associated with an increased risk of delirium, particularly in susceptible individuals.

    • Stress, sleep deprivation, emotional disturbances, infections. Psychological stressors, such as sleep deprivation and emotional distress, as well as infections, can also trigger delirium, especially in individuals with predisposing factors.

  • Essential Features:

    • Disturbed consciousness with cognitive difficulties. A hallmark of delirium is an altered level of consciousness, ranging from drowsiness to hyper-alertness, accompanied by cognitive impairments in attention, memory, and executive function.

    • Cognitive disturbances: thinking, memory, disorientation, perception. Delirium is characterized by a range of cognitive disturbances, including disorganized thinking, impaired memory, disorientation to time and place, and perceptual disturbances such as hallucinations and illusions.

    • Attention disturbances: loss of focus, confusion. Difficulty sustaining attention and maintaining focus on relevant stimuli is a core feature of delirium, leading to confusion and difficulty processing information.

    • Sundown syndrome: increased confusion in the evening. Many individuals with delirium experience a worsening of symptoms in the evening or at night, a phenomenon known as sundowning, which may be related to disruptions in circadian rhythms.

  • Clinical Picture:

    • Irritability, confusion, trembling, tachycardia, sweating, nausea, vomiting, impaired consciousness, seizures. Delirium can manifest with a variety of clinical signs and symptoms, including irritability, confusion, tremors, rapid heart rate, sweating, nausea, vomiting, impaired consciousness, and seizures.

    • Hallucinations (visual, auditory, tactile). Perceptual disturbances, such as visual, auditory, or tactile hallucinations, are common in delirium and can contribute to the individual's distress and disorientation.

    • Comorbidities: dehydration, electrolyte imbalance, infection, hepatic encephalopathy, metabolic disorders, tumors, B12 deficiency, hypoxia. Delirium often occurs in the context of underlying medical conditions, such as dehydration, electrolyte imbalance, infection, hepatic encephalopathy, metabolic disorders, tumors, B12 deficiency, and hypoxia, which may contribute to its development and severity.

  • Risk Factors:

    • Advanced age, cognitive impairment, metabolic failure, fluid/electrolyte imbalance, nutritional deficiencies. Older adults, individuals with pre-existing cognitive impairment, and those with metabolic disorders, fluid/electrolyte imbalances, and nutritional deficiencies are at increased risk of developing delirium.

    • Cardiovascular/respiratory diseases, infections, surgery, substance use/withdrawals. Medical conditions such as cardiovascular and respiratory diseases, infections, surgery, and substance use or withdrawal can also increase the risk of delirium.

  • Types:

    • Delirium tremors (DTs): alcohol withdrawal, can be fatal. A severe form of delirium associated with alcohol withdrawal, delirium tremens is characterized by autonomic hyperactivity, hallucinations, and seizures, and can be life-threatening if left untreated.

    • Hyperactive: agitation and restlessness. Individuals with hyperactive delirium exhibit increased motor activity, agitation, restlessness, and may be prone to aggression or wandering.

    • Hypoactive: apathy and quietness. Hypoactive delirium is characterized by decreased motor activity, apathy, lethargy, and reduced responsiveness to the environment.

    • Mixed: combination of hyper and hypo. Some individuals with delirium may exhibit a mixed presentation, with features of both hyperactive and hypoactive delirium.

  • Assessment:

    • Acute, sudden reduction in clarity, impaired focus, inattention, fluctuating consciousness, sundowning. Assessment of delirium involves evaluating the individual's level of consciousness, attention, and cognitive function, as well as identifying any precipitating factors or underlying medical conditions.

    • Illusions and hallucinations. Assessing for the presence of perceptual disturbances, such as illusions and hallucinations, is an important component of the evaluation of delirium.

    • Dramatic mood fluctuations. Individuals with delirium may exhibit rapid and unpredictable mood swings, ranging from agitation and irritability to anxiety and depression.

  • Diagnostics & Screening:

    • Confusion Assessment Method (CAM). A standardized assessment tool used to diagnose delirium based on the presence of key features such as acute onset, inattention, disorganized thinking, and altered level of consciousness.

    • Nealon/Champagn (NEECHAM) confusion scale. Another assessment tool used to evaluate confusion and cognitive impairment in individuals with delirium.

  • Nursing Intervention:

    • Treat cause, nutrition, antibiotics (if infection). Nursing interventions for delirium focus on addressing the underlying cause of the delirium, providing adequate nutrition and hydration, and administering medications such as antibiotics if an infection is present.

    • IVF for electrolyte imbalance, oxygen if hypoxic. Intravenous fluids may be administered to correct electrolyte imbalances, and oxygen therapy may be provided to address hypoxia.

    • Manage environmental stressors, keep patient calm. Creating a calm and quiet environment, minimizing environmental stressors, and providing reassurance and support can help reduce agitation and anxiety in individuals with delirium.

  • Outcomes:

    • Goal: Return to premorbid level of functioning. The primary goal of treatment for delirium is to resolve the underlying cause and restore the individual to their pre-morbid level of cognitive and functional abilities.

    • Long-term: Patient safety, orientation, treat underlying cause. Long-term goals of care include ensuring patient safety, promoting orientation to time and place, and addressing any underlying medical or psychiatric conditions that may contribute to the risk of recurrent delirium.

    • Short-term: Stable vital signs, normal skin turgor. Short-term goals of care include stabilizing vital signs, maintaining adequate hydration and nutrition, and preventing complications such as falls and infections.

  • Interventions

    • Treat Cause

    • Nutrition

    • Antibiotics for infection

    • IVF for Electrolyte Imbalance

    • Oxygen If Hypoxic

    • Treat Pain

    • Control Environmental Stressors

    • Keep Patient Calm, Quiet Environment

Mild Neurocognitive Disorder

  • Memory impairment is the main symptom. Although other cognitive deficits may be present.

  • Does not interfere with general cognitive functioning, ADLs, or socialization. General cognitive functioning, activities of daily living (ADLs), or socialization, allowing individuals to maintain independence and participate in meaningful activities.

Major Neurocognitive Disorder (Dementia)

  • Progressive, chronic cognitive impairments. Characterized by a gradual decline in cognitive abilities over time.

  • Significant cognitive decline in one or more domains. Such as memory, language, executive function, attention, or visuospatial skills.

  • Loss of ability to think, reason, remember, communicate. Which significantly impacts daily life and independence.

  • Changes in memory, judgment, language, abstract thinking, problem-solving, impulsive behavior, confusion. Memory loss, impaired judgment, language difficulties, impaired abstract thinking, difficulty problem-solving, impulsive behavior, and confusion.

  • Primary vs. Secondary

    • Primary: Irreversible, progressive, not secondary to other diseases (e.g., Alzheimer's). Represents neurodegenerative conditions such as Alzheimer's disease, frontotemporal dementia, and Lewy body dementia, which are not caused by other underlying medical conditions.

    • Secondary: Result of another pathologic process (e.g., AIDS-related dementia). Arises as a consequence of another medical condition, such as HIV/AIDS, vascular disease, traumatic brain injury, or substance abuse.

  • Etiology:

    • Amyloid plaques, age (strongest risk factor), genetics. The accumulation of amyloid plaques in the brain, increasing age, and genetic factors are major contributors.

    • More prevalent in women. Studies suggest that dementia, particularly Alzheimer's disease, is more prevalent in women than in men, potentially due to hormonal, genetic, and lifestyle factors.

    • Populations at risk: TBI, Down syndrome, vascular disease. Individuals with a history of traumatic brain injury (TBI), Down syndrome, or vascular disease are at increased risk of developing dementia.

  • Pathology of AD:

    • Tau protein changes, neurofibrillary tangles, cortex shrinking, hippocampal degeneration, enlarged ventricles, beta-amyloid plaques, brain atrophy. The pathological hallmarks of Alzheimer's disease include changes in tau protein, the formation of neurofibrillary tangles, shrinking of the cortex, degeneration of the hippocampus, enlargement of the ventricles, accumulation of beta-amyloid plaques, and overall brain atrophy.

  • Pathophysiology:

    • Damage to cerebral cortex. Affecting cognitive functions such as memory, language, and executive function.

    • Prevents accomplishing instrumental activities of daily living (IADLs). Such as managing finances, preparing meals, and using transportation.

    • Usually no change in LOC. Stable over 24 hours. Unlike delirium, where fluctuations in consciousness are common.

  • Assessment - AD

    • Denial, confabulation, perseveration, avoidance of questions. Individuals with Alzheimer's disease may exhibit denial of cognitive deficits, confabulation (creating false memories), perseveration (repetition of words or actions), and avoidance of questions about their cognitive abilities.

    • Cardinal symptoms: amnesia, aphasia, apraxia, agnosia, anomia, disturbances in executive functioning. The core symptoms of Alzheimer's disease include amnesia (memory loss), aphasia (language difficulties), apraxia (difficulty performing motor tasks), agnosia (difficulty recognizing objects), anomia (difficulty naming objects), and disturbances in executive functioning (impaired planning, problem-solving, and decision-making).

  • Stages of Alzheimer's

    • Stage 1 (mild): forgetfulness, possible depression. Characterized by mild memory loss, difficulty remembering recent events, and possible symptoms of depression.

    • Stage 2 (moderate): confusion, memory gaps, self-care gaps, apraxia, labile mood. Marked by increasing confusion, significant memory gaps, difficulty with self-care tasks, apraxia (difficulty performing motor tasks), and labile mood (rapidly changing emotions).

    • Stage 3 (moderate to severe): unable to identify familiar objects, advanced agnosia and apraxia. Characterized by an inability to recognize familiar objects or people, as well as advanced agnosia (difficulty recognizing objects) and apraxia (difficulty performing motor tasks).

    • Stage 4 (late): agraphia, hyperorality, hypermetamorphosis. Characterized by agraphia (inability to write), hyperorality (excessive chewing or putting objects in the mouth), and hypermetamorphosis (excessive touching of objects).

  • Manifestations by Stage

    • Mild: subtle changes, misplaces objects, forgets names. Individuals in the mild stage of Alzheimer's disease may exhibit subtle changes in behavior, such as misplacing objects and forgetting names.

    • Moderate: confused about time/place, needs help with routine tasks, confabulates, wandering, sundowning. Those in the moderate stage may become confused about time and place, require assistance with routine tasks, confabulate (create false memories), wander, and experience sundowning (worsening of symptoms in the evening).

    • Severe: difficulty communicating, atypical behavior, agraphia, hypermetamorphosis, hyperorality. In the severe stage, individuals may have difficulty communicating, exhibit atypical behavior, and develop agraphia (inability to write), hypermetamorphosis (excessive touching of objects), and hyperorality (excessive chewing or putting objects in the mouth).

  • Recognize Cues: Comprehensive Assessment

    • Mood, safety, cognition/perception, physical needs, communication, physical symptoms, mobility, vital signs, diagnostic/laboratory tests. A comprehensive assessment should evaluate mood, safety, cognition/perception, physical needs, communication abilities, physical symptoms, mobility, vital signs, and diagnostic/laboratory test results.

  • Recognize Cues: Focused Assessment

    • Delirium: Hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile). A focused assessment for delirium should assess for signs and symptoms such as hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile).

    • Dementia: Safety, as manifestations frequently worsen at night (sundowning) when the client may not be supervised well. A focused assessment for dementia should prioritize safety, particularly at night when symptoms may worsen (sundowning) and supervision may be limited.

  • Lab/Diagnostic Tests

    • Delirium: Chem panel. A chemistry panel (chem panel) may be performed to assess for underlying medical conditions contributing to delirium.

    • Alzheimer’s: Mini-Mental Status Exam (MMSE), Functional assessment tool. The Mini-Mental Status Exam (MMSE) is a widely used cognitive assessment tool, and a functional assessment tool may be used to evaluate the individual's ability to perform activities of daily living.

Implementation

  • Always identify yourself.

  • Call the person by his or her name at each meeting.

  • Speak slowly.

  • Use short, simple words and phrases.

  • Maintain face-to-face contact.

  • Be near the patient when talking, one or two arm lengths’ away.

  • Focus on one piece of information at a time.

  • Talk with the patient about familiar things.

  • Encourage reminiscing about happy times.

  • When the patient is delusional, acknowledge the patient’s feelings and reinforce reality.

  • Do not argue or refute delusions.

  • Have the patient wear eyeglasses or a hearing aid.

  • Keep the patient’s room well-lit.

  • Have clocks, calendars, and personal items (e.g., family pictures, Bible) in clear view.

  • Reinforce the patient’s pictures, nonverbal gestures, X’s on calendars, and other methods to present reality.

  • If a patient gets into an argument with another, separate the individuals. After approximately 5 minutes, explain your intervention. If the patient is verbally aggressive, then acknowledge the patient’s feelings and shift the topic to a familiar ground

Take Action - Nonpharmacologic

  • Education and support groups

  • Personal care

  • Music and Reminiscence Therapy

  • Craniosacral massage

  • Safety

Diet

  • Healthy diet: fish, fresh vegetables, and plant oils

  • The MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet

Safety Measures - Home

  • Ensure supervision, appropriate to stage of illness.

  • Consider placing bed mattress on floor to prevent injury from falling out of bed.

  • Note how to contact important people (spouse, children, EMS).

  • Ensure hot water and oven safety.

  • Prevent elopement/place tracking device on client.

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

Pharmacologic Interventions

  • "Start low and go slow"

  • Cholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine . Side effects: GI upset, muscle spasms, bradycardia (Monitor heart rate)

  • Selective serotonin reuptake inhibitors (SSRIs)

Evaluate Outcomes

  • Assess for changes in cognition/behavior frequently.

  • Assess for caregiver strain/Suggest respite.

  • Assess for medication adherence/effectiveness.