neurocognitive disorders

Neurocognitive Disorders

Learning Objectives

• Describe the impact of neurocognitive disorders on a client’s overall health.
• Explore epidemiological and etiological risk factors that contribute to clients experiencing neurocognitive disorders.
• Differentiate the clinical presentation of clients experiencing neurocognitive disorders.
• Explore the role of the nurse when caring for clients experiencing neurocognitive disorders.
• Apply the nursing process through the use of the clinical judgment functions while providing care to clients experiencing neurocognitive disorders.

Overview of Neurocognitive Disorders

• Types of Neurocognitive Disorders:
  • Delirium
  • Dementia
  • Cognitive decline
  • Several types of dementias.

Delirium

• Definition:
  • A disturbance in attention that develops over a short period of time, with an additional disturbance in cognition.

Dementia and Major Neurocognitive Disorders

• Definition of Dementia:
  • Frequently used to describe neurocognitive disorders, defined by the American Psychiatric Association (APA) as significant cognitive decline from a previous level of performance in one or more cognitive domains, which include:
  • Complex attention
  • Executive function
  • Learning and memory
  • Language
  • Perceptual-motor
  • Social cognition.
  • Interference with Independence:
  • These deficits interfere with independence in everyday activities and do not occur exclusively in the context of a delirium or are not better explained by another disorder (APA, 2013).

Delirium Compared to Dementia

Comparison Chart

Types of Neurocognitive Disorders

• Examples of Neurocognitive Disorders:
  • Alzheimer’s disease
  • Frontotemporal lobar degeneration (formerly Pick’s disease)
  • Lewy body disease
  • Vascular disease
  • Traumatic brain injury (TBI)
  • Substance/medication use
  • HIV infection
  • Prion disease
  • Parkinson’s disease
  • Huntington’s disease
  • Other medical conditions/multiple etiologies/unspecified (APA, 2013).

Delirium - Etiology

• Causes of Delirium include:
  • Intoxication or withdrawal (e.g., alcohol, cannabis, phencyclidine, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, amphetamines, cocaine)
  • Drugs (e.g., lithium, levodopa, steroids, digitalis, antidepressants, benzodiazepines)
  • CNS depressants
  • Stress
  • Sleep deprivation
  • Emotional disturbances.

Delirium - Comorbidities

• Common comorbidities associated with delirium include:
  • Dehydration
  • Electrolyte imbalance
  • Infection
  • Hepatic encephalopathy
  • Metabolic disorders
  • Tumors
  • B12 deficiency (Mayo Clinic, 2021b).

Alzheimer’s Disease - Etiology

• Risk Factors for Alzheimer’s Disease:
  • Presence of amyloid plaques
  • Age is the strongest risk factor
  • More prevalent in women
  • Populations at risk include those experiencing traumatic brain injury, Down syndrome, and vascular disease.

Vascular Disease Dementia - Etiology

• Etiology Factors:
  • Deficits with blood vessels
  • Hypertension
  • Reduced blood flow to the brain
  • Cerebrovascular "events"
  • Risk increases exponentially after age 65.

Lewy Body Dementia - Etiology

• Characteristics:
  • Presence of Lewy bodies in the brain.

Frontotemporal Lobe Dementia - Etiology

• Etiology Factors:
  • Family history (40% risk)
  • Genetic mutations.

Other Dementias - Etiology

• Common Causes include:
  • TBI (Traumatic Brain Injury)
  • HIV (Infection with the virus)
  • Prion (Genetic and eating contaminated meat)
  • Huntington’s disease (Genetic)
  • Parkinson’s disease (Destruction of the globus pallidum).

Dementia - Manifestations

Domains

• Cognitive Domains Affected:
  • Executive function
  • Planning
  • Complex attention
  • Processing speed
  • Learning/memory
  • Short-term memory
  • Perceptual/motor function
  • Everyday tasks
  • Social cognition.
  • Behavioral Implications:
  • Insensitivity to standards.

Dementia - Executive Function

• Major Manifestations:
  • Stops complex projects; focuses on one task at a time.
  • Needs others to plan activities and make decisions.
• Mild Manifestations:
  • More effort needed to complete multistage projects.
  • Difficulty multitasking.

Dementia - Complex Attention

• Major Manifestations:
  • Difficulty in environments with multiple stimuli; easily distracted by competing events in the environment.
  • Needs simple and restricted input.
  • Thinking takes longer, processing is slowed.
• Mild Manifestations:
  • Normal tasks take longer; require more double-checking.
  • Can think better without distractions such as TV, driving, etc.

Dementia - Learning/Memory

• Major Manifestations:
  • Repeats self in conversation.
  • Cannot keep track of a short list of items when shopping or planning.
• Mild Manifestations:
  • Difficulty recalling recent events.
  • Needs reminders and lists.
  • Note: Except in severe forms of major neurocognitive disorder, semantic, autobiographical, and implicit memory are relatively intact compared with recent memory.

Dementia - Language

• Major Manifestations:
  • Significant difficulties with expressive or receptive language.
  • Uses pronouns rather than names and general terms like "that thing".
• Mild Manifestations:
  • Noticeable word-finding difficulty.
  • Substitutes general for specific names of acquaintances.
  • Subtle grammatical errors.

Dementia - Perceptual/Motor

• Major Manifestations:
  • Significant difficulties with previously familiar activities and environments.
  • Often more confused at dusk (sundowning).
• Mild Manifestations:
  • Relies more on maps and others for directions.
  • Uses notes.
  • Frequently lost if not concentrating on tasks.
  • Less precise in parking.
  • Greater effort needed for spatial tasks.

Dementia - Social Cognition

• Major Manifestations:
  • Insensitivity to social standards of modesty and topics of conversation.
  • Makes unsafe decisions.
• Mild Manifestations:
  • Subtle behavior or attitude changes.
  • Decreased empathy and inhibition, restlessness.

Alzheimer's Disease - DSM-5 Criteria

• Criteria for Diagnosis:
  • Must show insidious onset, followed by gradual progression, with at least two domains impaired.
• Major Criteria:
  • Evidence of a genetic mutation from genetic testing and/or family history.
  • Evidence of memory and learning decline and at least one other cognitive domain.
  • Gradual, steadily progressive decline in cognition, without extended plateaus.
  • No evidence of mixed etiology.
• Mild Criteria:
  • Evidence of a genetic mutation from genetic testing and/or family history.
  • Evidence of memory or learning decline.
  • Gradual, steadily progressive decline in cognition, without extended plateaus.
  • No evidence of mixed etiology.

Alzheimer's – Manifestations by Stage

• Mild Stage:
  • Disease is not obvious, but friends and family notice subtle changes.
  • Misplaces objects, forgets names.
  • Trouble with planning/organizing.
  • May create neologisms (made-up words).
• Moderate Stage:
  • Confused about place/time.
  • Needs help with routine tasks like dressing appropriately.
  • Confabulates (makes up stories).
  • May wander.
  • Exhibits sundowning symptoms.
  • May have language difficulties.
• Severe Stage:
  • Difficulty communicating, responding to their environment, and controlling movement.
  • Displays atypical behavior (e.g., hostility).
  • Agraphia, hypermetamorphosis, and hyperorality may manifest.

Lewy Body Dementia - Core Diagnostic Features

• Core Features Include:
  • Fluctuating cognition
  • Recurrent visual hallucinations
  • Spontaneous features of parkinsonism
  • Rapid eye movement sleep behavior and severe neuroleptic sensitivity can be suggestive.
  • Gender Preferences: Men often present with rapid eye movement sleep behavior as the first manifestation, while women more often present with hallucinations. (Utsumi et al., 2020).
  • Clients often experience tactile hallucinations that prompt them to try to touch the object they are hallucinating.

Vascular Disease Dementia – Manifestations

• Cognitive Decline Features:
  • Decreased processing speed
  • Impaired executive function.

Traumatic Brain Injury (TBI) – Manifestations

• Key Symptoms:
  • Loss of consciousness
  • Posttraumatic amnesia
  • Disorientation and confusion
  • Neurological signs.

The Care Team Members

• Multidisciplinary Team Members:
  • Providers
  • Psychologists
  • Nurses
  • Assistive personnel
  • Recreational therapists
  • Adult day care providers
  • Security/emergency response personnel
  • Therapists (speech, music, physical, occupational)
  • Social workers
  • Hospice staff.

Nurse’s Role

• Responsibilities in Caring for Clients with Neurocognitive Disorders:
  • Provide equitable and sensitive care.
  • Maintain knowledge of neurocognitive disorders.
  • Exhibit compassion and empathy in treatment.
  • Ensure comfort for patients.
  • Foster self-awareness among caregivers.
  • Advocate for a least restrictive environment.
  • Ensure safety both at home and in inpatient settings.
  • Report to adult protective services if home environment is unsafe.
  • Educate families and caregivers.
  • Provide therapeutic presence by actively listening and offering support.
  • Use effective communication strategies, such as maintaining a calm tone, reinforcing reality, and using short, simple phrases while limiting choices.

Safety Measures – Home

• Recommendations Include:
  • Ensure supervision appropriate to the stage of illness.
  • Consider placing the mattress on the floor to prevent falls.
  • Keep contact information for key individuals accessible (spouse, children, EMS).
  • Ensure safety concerning hot water and oven use.
  • Prevent wandering by placing tracking devices on clients.
  • Notify local law enforcement if monitoring is needed.
  • Remove smoking materials.
  • Evaluate the house for safety hazards (e.g., poorly placed furniture, throw rugs).
  • Ensure secure locks and windows.
  • Install safety rails in hallways, bathrooms, and on steps.
  • Remove sharp objects from reach.
  • Restrict or forbid car use as needed; arrange for transportation services.
  • Explore the installation of sensor devices and web-based GPS systems.

Safety Measures – Inpatient

• Recommendations Include:
  • Ensure clients have access to hearing aids and eyeglasses.
  • Minimize mirrors that can increase agitation.
  • Install railings in hallways and grab bars in bathrooms to facilitate balance.
  • Ensure units are well-lit to minimize misinterpretation of shadows.
  • All clients should wear identification bracelets (and possibly monitors).
  • Judicious use of antianxiety medications may be necessary when clients become agitated.
  • Minimize the use of restraints, as these can promote anxiety.

Recognize Cues: Comprehensive Assessment

• Areas to Assess Include:
  • Mood: Safety, depression, hostility, suicidality
  • Cognition/Perception: Hallucinations, confabulations
  • Physical Needs: Assessment of ADLs, self-care capabilities
  • Communication: Neologisms, word-finding issues
  • Physical Symptoms: Symptoms like anosmia, tremors, sweating, hyperactivity, nausea/vomiting
  • Mobility: Assessment of mobility issues
  • Vital Signs: Regular monitoring
  • Diagnostic/Laboratory Tests: Order appropriate tests to diagnose issues.

Recognize Cues: Focused Assessment

• For Delirium:
  • Symptoms like hyperactivity, trembling, tachycardia, sweating, tremors, nausea, vomiting, impaired consciousness, seizures, and hallucinations (visual, auditory, and tactile).
• For Dementia:
  • Alzheimer’s: Neologisms, perseveration, confabulation, apraxia, agnosia, agraphia, hypermetamorphosis, and hyperorality.
  • Safety is critical as manifestations often worsen at night (sundowning) when supervision may be inadequate.
  • Fronto-temporal Lobar: Risky and socially inappropriate behaviors may endanger client safety.
  • Lewy Body: Includes cognitive impairment, visual hallucinations, and rapid eye movement sleep behavior disorder.
  • Drug-induced: Symptoms include irritability, anxiety, sleep disturbance, dysphoria, apathy, hypersomnia, incoordination, ataxia, motor slowing, and loss of emotional control.
• For Vascular Dementia:
  • Cognitive decline with signs of previous strokes.
• For TBI:
  • Symptoms like seizures, visual field cuts, anosmia, and hemiparesis.
• For HIV:
  • Symptoms including fever, headache, muscle and joint pain, rash, diarrhea, weight loss, cough, night sweats, sore throat, mouth sores, and swollen lymph glands.
• For Prion Disease:
  • Symptoms include myoclonus and ataxia.
• For Parkinson's Disease:
  • Includes apathy, depressed mood, anxiety, hallucinations, delusions, personality changes, rapid eye movement sleep behavior disorder, and daytime sleepiness.
• For Huntington's Disease:
  • Symptoms like bradykinesia, chorea, executive function decline.

Lab/Diagnostic Tests

Testing Methods

• For Delirium: Conduct chemical panel tests.
• For Alzheimer’s:
  • Use positron emission tomography (PET) to detect amyloid plaques.
  • Mini-Mental State Examination (MMSE) to determine the stage:
  • Score 22 to 26 = mild
  • Score 18 to 20 = moderate
  • Score 0 to 10 = severe.
  • Additional functional assessment tools may assess functioning to determine stage (eight stages).
• For Frontal Temporal Lobar Dementia: Utilize CT or MRI imaging.
• For Lewy Body Dementia: Rely on patient history.
• For Vascular Dementia:
  • Use CT, MRI, patient history, and physical exam.
• For Substance Use:
  • Focus on taking patient history and conducting labs to detect current usage.
• For HIV:
  • Labs to detect the virus must be conducted.
• For Prion Disease:
  • Autopsy and patient history used post-mortem.
• For Parkinson’s Disease:
  • Evaluation focused on history of motor deficits.
• For Huntington’s Disease:
  • Genetic testing is essential.

TBI Diagnosis

• Imaging Techniques:
  Use CT or MRI for diagnosis.


• Key Manifestations:

• Traumatic amnesia
• Confusion
• Disorientation
• Loss of consciousness
• Posturing.

Comparison Factors

Analyze Cues/Prioritize Hypotheses

• Priority is safety.
  • Focus on managing manifestations and connecting with resources.

Generate Solutions

• Approach must be patient-centered:
  • Involve clients in planning early in the diagnosis.
  • Engage families and caregivers in the care plan.
  • Connect clients with valuable resources like:
  • Alzheimer’s Association
  • Alzheimer’s Disease Education and Referral Center
  • Association for Frontotemporal Degeneration
  • Creutzfeldt-Jakob Disease Foundation
  • Family Caregiver Alliance
  • National Center on Caregiving
  • Lewy Body Dementia Association
  • National Family Caregiver Association
  • National Hospice Foundation
  • National Palliative Care Foundation
  • National Respite Care Network
  • Well Spouse Association

Take Actions – Nonpharmacologic

• Strategies Include:
  • Education and support groups for families and caregivers.
  • Personal care assistance (bathing, dressing, eating, toileting).
  • Music/reminiscence therapy, shown to improve self-esteem and alleviate depression.
  • Consider craniosacral massage as a form of therapy.
  • Ensure safety through environmental adjustments.
  • Study of herbal therapies as adjuncts to treatment is ongoing.

Personal Care Recommendations

• Strategies for Daily Care:
  • Clothes should be easy to don and doff.
  • Choose clothing ahead of time, labeling with client’s name.
  • Monitor food and fluid intake regularly.
  • Use finger foods and check for pocketing during meals.
  • Weigh clients weekly to monitor nutrition.
  • Music has potential to aid in stimulating appetite.
  • Consider food delivery services to facilitate meal access.
  • Encourage independence with activities of daily living (ADLs) as long as possible.
  • Encourage the use of hearing aids, which have been shown to decrease the risk of cognitive decline (ASHA, 2019).

Diet Recommendations

• Promote the Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND):
  • A combination of Mediterranean and DASH diets.
  • Incorporate flavanols and omega-3 fatty acids, which have been shown to delay progression of cognitive decline.

Take Actions – Pharmacologic

• Medication Approaches Include:
  • Delirium: Address the underlying cause and use benzodiazepines for delirium tremens.
  • Alzheimer’s:
  • Cholinesterase inhibitors such as donepezil, tacrine, rivastigmine, and galantamine for symptom management.
  • Aducanumab for progression of disease.
  • Other Dementias: Focus on targeting the cause or symptoms, which may include:
    • Antidepressants and antipsychotics (particularly for Lewy body).
    • Statins, anticoagulants, aspirin for vascular disorders.
    • Levodopa and COMT inhibitors for Parkinson’s.
    • Antiretrovirals for treatment of HIV.
    • Tetrabenazine for Huntington’s Disease.

Evaluate Outcomes

• Key Considerations:
  • Regularly assess for changes in cognition and behavior.
  • Monitor caregiver strain and suggest respite care services as needed.
  • Regularly assess for medication adherence and effectiveness.