Cognition and Delirium MH 8

Cognition Defined: Cognition refers to the brain's multi-faceted ability to function. This includes several specific processes:
- The ability to process information.
- The ability to retain or store information.
- The ability to use stored information in a practical or intellectual capacity.
Core Components of Cognition: Major functions included under the umbrella of cognition are:
- Reasoning
- Judgment
- Perception
- Attention
Cognitive Disorders: A cognitive disorder occurs when there is a specific impairment in these higher-level brain functions.

The JAMCO Assessment: A specific tool recommended for measuring memory and cognitive status is designated by the acronym JAMCO.
JAMCO Components: Each letter in the acronym represents a critical area of assessment:
- J: Judgment
- A: Affect
- M: Memory
- C: Cognition
- O: Orientation

Medical Definition: Delirium is defined by two primary characteristics:
- An altered level of consciousness.
- Impaired cognition.
Temporal Nature: Unlike chronic conditions, delirium is strictly acute.
- Onset: It possesses a rapid, sudden onset.
- Duration: Delirium is characterized by a short duration.
- Reversibility: The condition is temporary and reversible if the underlying cause is addressed.
Fluctuation: Symptoms of delirium are not static; they typically fluctuate throughout the course of a 24-hour day.
Long-term Deficits: While delirium itself is temporary, failing to correct the underlying cause can lead to permanent damage or neurological deficits. The patient may deteriorate further rather than returning to their baseline.

Common Underlying Causes:
- Physiological Stressors: Fever, acute illness, and pain.
- Respiratory Issues: Hypoxia (lack of oxygen).
- Metabolic Disruption: Fluid or electrolyte imbalances. Specific examples include dehydration or abnormal levels of potassium ( $K^+$ ) and sodium ( $Na^+$ ).
- Endocrine Issues: Hormonal imbalances.
- Environmental Factors: Significant changes in environment, which are particularly disruptive to elderly clients.
Pharmacological Triggers: Medications and anesthesia are major contributors.
- Ketamine: Specifically highlighted as a medication that can cause a patient to emerge from treatment appearing like a "totally different human."
- Post-Surgical Reactions: Anesthesia frequently causes patients to react poorly or experience hallucinations upon waking.
Increased Vulnerability:
- Renal or Liver Impairment: Patients with kidney or liver issues are at higher risk because these organs are responsible for the metabolism and excretion of drugs and toxins.
- Pre-existing Conditions: Patients in the early stages of dementia have a significantly increased risk of experiencing delirium.

Cognitive and Psychological Symptoms:
- Disorientation.
- Impaired short-term memory.
- Sleep disturbances.
- Mood swings.
- Loss of Normal Signals: Patients may forget basic biological needs, such as forgetting to eat or drink.
Perceptual Disturbances: Patients may experience various forms of altered reality, which can cause them to feel frightened or threatened:
- Hallucinations: Sensory experiences without external stimuli.
- Illusions: Misinterpretations of real external stimuli.
- Delusions: Fixed false beliefs.
Communication Styles: Speech patterns in delirious patients may be:
- Fragmented
- Pressured
- Slurred
Psychomotor Activity: Behavior may swing between extremes:
- Agitation: Increased, restless activity.
- Lethargy: Sluggishness or lack of energy.

The Primary Goal: The most critical intervention is to identify and treat the underlying cause. Simply treating the symptoms will not fix the problem if the cause persists.
Environmental Management:
- Decrease Stimuli: This is considered the most effective way to manage a patient out of their normal state of mind. Chaos and high-stimulus environments will worsen the condition.
- Lighting: Provide good lighting to reduce confusion and illusions.
Communication and Interaction:
- Frequent Orientation: Unlike dementia, healthcare providers should reorient the patient to reality as often as necessary.
- Simplicity: Use simple instructions and a calm, soothing voice.
- Decision Making: Patients in this state should not be allowed to make their own decisions due to poor judgment.
Validation Therapy:
- Healthcare providers must validate the patient's feelings. Even if a hallucination or delusion is not real, the feeling the patient has is real to them.
- Maintain a distinction between validation and false reassurance; do not give false reassurance.
Safety Measures:
- High Injury Risk: Delirious patients are at high risk for injury due to poor judgment and disorientation.
- Supervision: Increased supervision is required to ensure safety.
- Restraints: These should always be used as a last resort.

Reversibility: Delirium is acute and treatable; Dementia is a progressive, chronic condition that generally results in severe impairment unless the patient expires from other causes first.
Reorientation Approach:
- In Delirium: Reorient the patient frequently.
- In Dementia: Reorientation is often ineffective and can lead to unnecessary arguments. Nursing care for dementia involves "going with it."
Case Example (Dementia): An anecdote was shared regarding a patient named Tanika and a sweet patient who believed they were getting on a bus. Tanika allowed the patient to believe this rather than upsetting them through correction.

Participant Observation: One participant, Brie, noted that delirium can occur specifically after surgery due to the effects of anesthesia.
Instructor Note on Ketamine: The instructor expressed a personal dislike for Ketamine because of the profound behavioral and perceptual changes it causes in patients.
Discussion on Logic and Outcomes: The instructor emphasized that if an electrolyte imbalance (like abnormal sodium) is the cause and it is not corrected, it eventually leads to long-term deficits rather than remaining "delirium."