Module 8: Neurocognitive Disorders; Eating Disorders
Overview of Cognition and Neurocognitive Disorders
Cognition Definition and Human Impact:
Cognition provides clarity and meaning to a person's life.
Neurocognitive disorders distort meaning and cloud perception.
Cognitive impairments affect mental capacity as well as physical, psychological, social, and spiritual dimensions.
Cognitive Domains:
Lower-Level Cognitive Domains:
Involves rapid, automatic processing and environmental awareness.
Key functions include noticing surroundings, attending, and orienting.
Examples include seeing a clock on the wall or hearing a buzzing sound in the room.
Primary clinical site affected by delirium.
Higher-Level Cognitive Domains:
Requires sustained mental effort and directed attention.
Key functions include analyzing information, planning, critical thinking, problem-solving, reasoning, and recalling knowledge.
Pathophysiology of Neurocognitive Disorders (NCDs):
Characterized by primary clinical deficits in cognitive function.
Driven by underlying brain pathology and classified as acquired deficits rather than developmental impairments.
Labeled according to etiology (e.g., traumatic brain injury [TBI], cardiovascular conditions, HIV infection, or dementia).
Dementia: A broad umbrella term describing a collection of symptoms resulting in progressive deterioration of cognitive function and perceptual capacity.
Delirium: Clinical Manifestations and Risk Factors
Definition and Core Characteristics:
A distinct neurocognitive disorder impacting lower-level cognitive domains.
Characterized by an acute, abrupt onset (developing over to ).
Generally brief and reversible once the underlying biological cause is identified and treated.
Most frequently encountered in hospitalized older adults with complex medical, surgical, or neurological conditions.
Clinical Presentation:
Acute disorientation, confusion, disorganization of thought, agitation, and extreme fearfulness.
Inability to recognize healthcare providers or familiar individuals (e.g., stating they have never seen their assigned nurse before).
Difficulty recalling location, identity, or current events.
Perceptual and Cognitive Disturbances:
Brief visual hallucinations or illusions (e.g., reporting seeing a cat or dog run across the room).
Patient stating that "something is not right" due to altered environmental perception.
Behavioral Variations:
Hyperactive: Scanning the room, intense agitation, wandering, screaming/crying out, pulling at IV lines, catheters, or endotracheal tubes, and potential striking out/striking healthcare staff.
Quietly Delirious (Hypoactive): Patient appears calm and settled on the surface, but exhibits severe mood swings and underlying erratic behaviors.
Etiologies and Risk Factors:
Systemic or localized infections.
Prolonged hospitalization stay.
Pre-existing cognitive impairment.
Physical immobilization (e.g., post-hip or back surgery).
Severe dehydration and fluid/electrolyte imbalances.
Polypharmacy, multiple IV infusions, and broad-spectrum antibiotics.
Severe sleep deprivation due to continuous hospital interruptions.
Uncorrected sensory deficits (vision or hearing impairments).
Delirium: Nursing Process and Interventions
Assessment and Diagnostic Workup:
Perform comprehensive mental status exams alongside thorough neurological and physical evaluations.
Obtain precise shift report data to differentiate new acute changes from pre-existing baseline deficits.
Assess for illusions, hallucinations, wandering behaviors, and self-care deficits.
Evaluate sensory needs: locate, clean, and provide visual and hearing aids (e.g., clean eyeglasses, functional hearing aids).
Nursing Diagnoses:
Risk for Injury (Highest Priority): Evidenced by sensory/perceptual deficits, acute confusion, hallucinations, and fear.
Altered Mental Status.
Impaired Sleep Pattern: Related to nighttime disorientation and environmental disturbances.
Impaired Verbal Communication: Secondary to disorganized thinking or hypoactive/quietly delirious states.
Self-Care Deficit: Leading to risk for fluid volume imbalance and constipation (e.g., failure to eat food on breakfast trays).
Nursing Interventions Classification (NIC):
Provision of a safe, therapeutic environment for the confused patient.
Promptly identify, investigate, and correct the underlying physical etiology (e.g., uncontrolled pain, infection, dehydration).
Implement frequent, structured neurological checks (e.g., neuro checks).
Ensure continuous supervision and observation to prevent self-harm or falls; avoid leaving the patient unmonitored.
Avoid placing patients in physical restraints as an initial response; investigate root causes of agitation first.
Administer physician-ordered PRN medications for severe, unmanageable anxiety or agitation.
Provide environmental orientation cues: display clocks, calendars, and indicators for time of day, season, and year.
Keep patient room doors open to allow visual monitoring and avoid isolation.
Advocate for continuity of care providers to maintain patient rapport and stability.
Validate and acknowledge patient fears and feelings rather than dismissing visual disturbances.
Evaluation:
Patient remains physically safe and free from injury.
Re-orientation returns to pre-admission cognitive baseline status by discharge.
Clinical Distinctions: Delirium vs. Mild/Major Neurocognitive Disorders
Onset and Duration:
Delirium: Rapid, acute onset; resolves within to upon treating the primary cause.
Mild/Major NCD: Insidious, slow onset; progressive and irreversible.
Cognitive Domain Involvement:
Delirium: Primary impairment in lower-level domains (attention, orientation).
Mild/Major NCD: Progressive decline from a previous level of performance across one or more domains: complex attention, executive function, learning and memory, language, perceptual-motor skills, and social cognition.
Reversibility:
Delirium: Generally reversible.
Mild/Major NCD: Non-reversible and chronic.
Specialized Neurocognitive Terminology
Agraphia: Impairment or loss of a previously acquired ability to write.
Apraxia: Impairment of motor activities despite intact motor function (e.g., inability to dress, put on a jacket, or execute purposeful movements).
Aphasia: Loss of the ability to understand or express spoken speech.
Agnosia: Loss of the ability to recognize self in a mirror, familiar individuals, family members, or familiar auditory stimuli.
Confabulation: The unconscious creation of fabricated or distorted stories to fill in memory gaps; serves as a protective cognitive defense mechanism rather than intentional lying.
Hyperorality: The persistent need to examine and explore objects by mouth, tasting, or chewing non-food items.
Preservation (Perseveration): Uncontrollable, repetitive repetition of a particular word, phrase, or gesture beyond the point of context (e.g., repeating "hello, hello, hello").
Sundowning: Phenomenon characterized by heightened confusion, anxiety, and severe mood fluctuations occurring after twilight and into the night.
Alzheimer's Disease: Etiology, Pathophysiology, and Stages
Epidemiology and Overview:
Most common major neurocognitive disorder.
Affects an estimated () older adults.
Severe memory loss is not a normal physiological component of aging.
Risk Factors and Etiology:
Genetics: Specific genetic mutations guarantee disease development in approximately of cases. Family history of dementia significantly increases susceptibility.
Head Trauma: History of repeated brain injuries (e.g., professional football players, boxers).
Pathophysiology:
Insidious and progressive neurodegeneration.
Neurotransmitters: Significant deficit in Acetylcholine () production, impairing memory and learning processing.
Amyloid Plaques: Accumulation of extracellular sticky protein clumps between nerve cells that interrupt intercellular signal transmission.
Neurofibrillary Tangles: Intracellular accumulation of abnormal twisted tau protein strands inside neurons.
Stages of Alzheimer's Disease:
Stage 1: No apparent clinical symptoms.
Stage 2: Early short-term memory loss; patient retains insight into deficit, often instituting rigid routines to compensate; symptoms typically unnoticeable to external observers.
Stage 3 (Mild Cognitive Decline): Deficits become noticeable to family and friends; patient gets lost while driving, experiences difficulty recalling words or names, and exhibits impaired planning and organizational abilities.
Stage 4: Continued cognitive decline; forgetting major life events, inability to comprehend complex current events (e.g., news, politics); emergence of confabulation.
Stage 5 (Moderate Cognitive Decline): Inability to perform Activities of Daily Living (ADLs) independently (hygiene, grooming, dressing, eating); loss of memory for phone numbers, addresses, and close relatives' names; location disorientation; placement in secured dementia units with wander alarms; hyperorality and tactile exploration (reaching out, holding onto people/objects).
Stage 6 (Severe Cognitive Decline): Development of urinary and fecal incontinence; severe speech fragmentation; high risk of wandering and agitation; physical expressions of frustration (e.g., hitting own thigh or arm); retainment of procedural memory (e.g., observing and attempting to memorize door access keypad codes).
Stage 7 (End-Stage / Severe Decline): Total absence of recognition of familiar individuals; bedridden state; complete loss of swallowing reflex requiring enteral nutrition (e.g., Gastrostomy tube [G-tube] feedings); requires repositioning every two hours () to maintain skin integrity and prevent breakdown.
Alzheimer's Disease: Nursing Management and Interventions
Nursing Diagnoses:
Disturbed Sensory Perception.
Risk for Self-Harm / Injury (secondary to wandering or physical self-striking).
Self-Care Deficit.
Impaired Sleep Pattern.
Altered Mental Status.
Therapeutic Interventions:
Promote Independence: Allow patients to complete tasks they can still perform (e.g., holding a toothbrush, washing their face with a washcloth, pulling up pants, zipping jackets, putting on socks, opening ketchup packets or inserting straws). Avoid rushing tasks; educate families on maintaining patient autonomy to decrease frustration.
Environmental Direction: Utilize written signs and clear visual cues for orientation (e.g., directional signs reading "Restroom this way" or "Milieu this way").
Pharmacological Considerations & Warnings:
Avoid the routine use of typical or atypical antipsychotic medications due to increased risk of cerebrovascular accidents (strokes) and mortality in older adults with dementia.
Restraint Reduction: Minimize physical and chemical restraints; evaluate underlying triggers for agitation.
Supportive Services:
Refer families to financial assistance programs and caregiver support groups.
Respite Care: Temporary care services providing relief to primary family caregivers. Registered Nurses (RNs) or Physical Therapists (PTs) perform initial home assessments to determine the required level of supportive care.
Eating Disorders: Shared Characteristics and Anorexia Nervosa
Common Milieu and Clinical Characteristics:
Shared psychological complexities surrounding food relationships.
Susceptibility to staff splitting; requires strict interprofessional rules, unified staff boundaries, and structured schedules.
Anorexia Nervosa: Core Features:
Characterized by an intense, irrational fear of gaining weight or becoming fat.
Refusal to maintain adequate nutritional intake despite physiological hunger.
Alterations in taste perception, appetite, and satiety/fullness signals.
Implementation of rigid weight goals, severe calorie restriction, excessive exercise, and compensatory purging behaviors.
Compensatory Behaviors and Purging Methods:
Self-induced vomiting.
Excessive, compulsive exercise regimes.
Abuse of laxatives, diuretics, enemas, central nervous system stimulants, or thyroid hormone medications to accelerate metabolism.
Diagnostic Criteria and Comorbidities:
DSM Criteria: Restriction of energy intake relative to requirements leading to significantly low body weight; intense fear of weight gain; distorted body image perception.
Severity Grading: Based on Body Mass Index ():
Severe Anorexia: to .
Moderate Anorexia: to 17\,\text{kg/m}^2$.\n * *High-Risk Populations*: Athletes involved in aesthetic or weight-class sports (e.g., gymnastics, rowing, figure skating).\n * *Comorbidities*: Bipolar disorder, anxiety disorders, major depressive disorder, PTSD, and substance use disorders.\n\n* **Psychodynamics and Cognitive Patterns**:\n * Severe body image distortion (e.g., viewing oneself as severely overweight despite extreme emaciation).\n * Compulsive behaviors: Frequent body weighing, measuring individual body parts in mirrors.\n * Impaired emotional identification, regulation, and processing; lack of clinical insight.\n * Belief that perceived control benefits outweigh physical harms.\n * Driven by deep-seated insecurities; starvation serves as a coping mechanism to avoid negative emotions.\n\n* **Medical Complications and Refeeding Syndrome**:\n * **Refeeding Syndrome**: A potentially fatal metabolic complication occurring when massive nutritional reinforcement is reintroduced too rapidly to a severely malnourished patient.\n * *Prevention*: Reintroduce nutrients at an extremely slow, gradual pace under close medical monitoring.\n * *Medical Management*: Initial medical stabilization, specialized dietitian consultation, and routine weight tracking (2\times3\times per week).\n * *Pharmacotherapy*: Core anorexia symptoms do not show strong responsiveness to psychotropic medications. Incorporate stress reduction modalities (e.g., yoga).\n\n# Bulimia Nervosa\n\n* **Core Features and Binge Dynamics**:\n * Recurrent episodes of uncontrolled binge eating defined as consuming an excessive amount of food (typically 1500\,\text{kcal}5000\,\text{kcal}2\text{-hour} period; equivalent to two party-size bags of potato chips).\n * Binge episodes are immediately followed by compensatory purging or extreme restriction.\n * **Distinction from Anorexia Nervosa**:\n * In Anorexia Nervosa, fear of weight gain is the continuous primary driving force.\n * In Bulimia Nervosa, fear of weight gain occurs as a panic response to the binge behavior.\n * **Body Weight Profile**: Individuals with bulimia nervosa typically maintain a normal or slightly above-normal body weight range.\n\n* **Pathophysiology and Complications**:\n * Severe electrolyte imbalances and fluid shifts secondary to repetitive purging.\n * Recurrent vomiting causes gastric acid exposure leading to severe tooth enamel erosion and dental caries (dentists are frequently the first clinicians to spot bulimia).\n * Risk of esophageal tears or rupture due to forced upper gastrointestinal tract stress.\n * Purging triggers a transient release of endorphins, providing temporary psychological relief and reinforcing the purging cycle.\n * Neurobiological changes impair the patient's capacity to modulate risk versus reward behaviors.\n\n* **Epidemiology and Interventions**:\n * Onset typically occurs in late adolescence; prevalence peaks in young adulthood.\n * Heritability estimated at approximately 60\%60\%).\n * **Milieu Management**: Interruption of the binge-purge cycle through direct observation before and after meals (e.g., structured monitoring for 1 hour post-meals).\n * **Psychotherapy**: Primary focus on restructuring negative body attitudes and cognitive distortions; utilize Dialectical Behavior Therapy (DBT) and Interpersonal Therapy (IPT).\n * **Pharmacotherapy**: Antidepressants (such as SSRIs) are effective in reducing binge-purge frequency.\n\n# Binge Eating Disorder (BED)\n\n* **Core Clinical Features**:\n * Characterized by recurrent episodes of consuming excessive quantities of calories in a short timeframe (e.g., within a 2\text{-hour}$$ window) past the point of comfortable physical fullness.
Bingeing occurs without the compensatory purging, vomiting, or excessive exercise seen in bulimia nervosa.
Causes substantial psychological distress, shame, guilt, and disgust.
Etiology and Contributing Factors:
Media influences and cultural thinness ideals.
Emotional eating patterns used to soothe psychological distress.
Social weight stigma, body discrimination, and negative stereotyping.
History of severe trauma, specifically emotional neglect in early life.
Nursing Process and Clinical Management:
Assessment: Monitor vital signs, conduct thorough nutritional pattern evaluations, and explore trauma history.
Communication Strategy: Maintain a neutral, empathetic, non-judgmental approach; strictly avoid stigmatizing or judgmental language.
Psychoeducation: Provide guidance focused on moderation, portion control, and mindful eating.
Self-Monitoring: Instruct patients to keep emotional journals tracking feelings, triggers, and circumstances surrounding binge episodes.
Pharmacotherapy: Utilize FDA-approved medications for binge eating disorder alongside psychotherapy to control binge urges.