Delirium & Dementia

Alterations in Cognitive Functioning

Delirium and Dementia Overview

  • Cognition: Higher brain functions that may be disrupted or impaired, leading to neurocognitive disorders.

  • Neurocognitive Disorders: This includes various disruptions in cognitive function that can affect daily life and overall quality of life for patients.

Key Domains of Cognitive Function

  • Perceptual-Motor Function: Includes visual perception, visuoconstructional reasoning, and perceptual-motor coordination.

  • Language: Encompasses object naming, word finding, fluency, and grammar/syntax comprehension.

  • Executive Function: Involves planning, decision-making, working memory, and response inhibition.

  • Learning and Memory: Covers types of recall, recognition memory, and both semantic and autobiographical long-term memory.

  • Complex Attention: Including sustained, divided, and selective attention; processing speed.

  • Social Cognition: Recognition of emotions and theory of mind; self-insight.

Delirium

Definition and Characteristics

  • What is Delirium?: A syndrome characterized by a disturbance in consciousness along with cognitive changes; develops rapidly, often in hours, and is prevalent in older adults (80% in terminally ill patients).

  • Etiology: Associated with identifiable physiological or cerebral disturbances from diseases or drug-related issues.

  • Risk Factors:

    • Increased severity of physical illness

    • Old age

    • Hearing impairment

    • Decreased food and fluid intake

    • Medications

    • Preexisting cognitive impairment

  • Cultural Consideration: Certain cultural practices, such as those of Jehovah's Witnesses regarding birthdays, may affect communication and should not be mistaken for disorientation.

Identifiable Causes

  • Infections:

    • Systemic: Sepsis, urinary tract infection, pneumonia.

    • Cerebral: Meningitis, encephalitis, HIV, syphilis.

  • Physiological/Metabolic Causes:

    • Hypoxemia, renal/hepatic failure, electrolyte disturbances.

    • Dehydration, sleep deprivation, and exposure to toxins (e.g., gasoline).

  • Drug-Related Causes:

    • Intoxication: Anticholinergics, lithium, alcohol, sedatives, and hypnotics.

    • Withdrawal: From alcohol, sedatives, and hypnotics; also includes reactions to anesthesia and illicit drugs.

Drug-Related Delirium

  • Commonly responsible medications causing delirium:

    • Anesthesia agents

    • Anticonvulsants

    • Anticholinergics

    • Antidepressants

    • Antihistamines

    • Antihypertensives

    • Antineoplastics

    • Antipsychotics

    • Narcotics, benzodiazepines, and various other drug classes.

Nursing Process in Delirium
Application #1: Assessment

  • Cognitive Indicators:

    • Difficulty in attention and orientation

    • Presence of sensory disturbances like illusions or hallucinations

    • General appearance may feature disturbed psychomotor behavior.

  • Mood and Affect: Rapid and unpredictable mood shifts, possibly showing signs of fragmented thought processes.

Application #2: Continuing Assessment

  • Intellectual and Sensorium Changes:

    • Sensory disturbances; decreased environmental awareness

    • Impaired judgment with possible illusions or headaches

  • Self-Care Considerations: Patients may struggle with self-care signals related to hunger/thirst or urination needs.

Application #3: Data Analysis and Nursing Diagnoses

  • Identified Risks:

    • Risk for injury

    • Acute confusion

  • Outcome Goals:

    • Freedom from injury

    • Increased orientation and reality contact

    • Maintenance of adequate nutrition and fluid balance.

Application #4: Interventions

  • Nursing Actions:

    • Do not assign unsafe responsibilities to the patient.

    • Involve the patient in decision-making as appropriate.

    • Monitor functioning closely and provide factual feedback concerning misperceptions.

    • Maintain low-noise environments and promote rest, while avoiding prolonged daytime naps.

Delirium Treatment

  • Pharmacological Options:

    • Antipsychotics (e.g., haloperidol, 0.5-1mg) for agitation or psychotic symptoms.

    • Benzodiazepines (e.g., lorazepam) for sedative-hypnotic withdrawal but cautious use due to potential for worsening delirium in older adults.

  • Supportive Measures:

    • Ensure sufficient nutrition and hydration to aid recovery, potentially using IV fluids if necessary.

Prognosis for Delirium

  • Primary Focus: Identify and treat underlying causes to reduce risk of recurrence, as patients with prior episodes are at heightened risk of additional delirium in the future.

Community-Based Care for Delirium

  • Post-Hospital Care: Need for referrals for ongoing cognitive symptoms after discharge.

Dementia

Definition and Characteristics

  • What is Dementia?: A progressive cognitive impairment characterized by multiple cognitive deficits without changes in consciousness, typically starting with memory issues.

  • Etiology: Various causes identified, often with decreased metabolic activity in the brain found postmortem.

Cognitive Deficits in Dementia

  • Key Symptoms:

    • Aphasia: Deterioration of language function.

    • Apraxia: Impaired execution of motor functions despite preserved physical ability.

    • Agnosia: Inability to recognize or name objects despite preserved sensory function.

    • Disturbance in Executive Function: Challenges with abstract thinking and planning.

Differences Between Delirium and Dementia

  • Delirium: Rapid and brief onset with disordered speech.

  • Dementia: Gradual and insidious onset, featuring progressive deterioration without affecting consciousness.

Stages of Dementia

  1. Mild Stage:

    • Symptoms: Forgetfulness, difficulty finding words, anxiety about losses; may begin to avoid social settings.

  2. Moderate Stage:

    • Symptoms: Confusion and progressive memory loss; can no longer perform complex tasks but remains oriented in familiar surroundings.

  3. Severe Stage:

    • Symptoms: Significant personality and emotional changes; potential for delusions and confusion regarding identity of familiar people.

Types of Dementia

  • Alzheimer's Disease: Progressive brain disorder marked by gradual cognitive decline, motor function loss, personality changes, hallucinations, and hygiene neglect.

  • Lewy Body Dementia: Involves both cognitive and motor symptoms; presents with extensive neuropsychiatric symptoms like delusions and hallucinations.

  • Vascular Dementia: Characterized by abrupt onset and fluctuations in cognitive function, often related to vascular lesions in the brain.

  • Frontotemporal Lobar Degeneration (Pick's Disease): Manifests with profound personality changes, emotion blunting, loss of social skills and inhibitions, language abnormalities. and is typically characterized by early-onset (50-60) dementia with rapid decline (death in 2-5 years)

  • Prion Disease (Creutzfeldt-Jakob Disease): Rare and rapidly progressing dementia due to abnormal protein folding; symptoms include vision changes and coordination loss. death in few months

  • Secondary Dementias: Includes dementia related to HIV infection, Parkinson’s Disease, Huntington’s Disease, and traumatic brain injuries.

  • Parkinson’s Disease: slowly progressive, characterized by tremor, rigidity, bradykinesia and postural instability

  • Huntingtons Disease manifestations include facial contortions, twisting, turning and tongue movements. Personality changes are the initial psychosocial manifestations followed by memory loss, decreased intellectual functioning and other signs of dementia. begins in late 30s or early 40s and can last 10-20 years.

  • Korsakoff Syndrome - Dementia caused by long term use of alcohol

Treatment and Prognosis for Dementia

  • Importance of Identification: Recognition of underlying causes is crucial for efficacy in therapeutic strategies.

Treatment Approaches:

  • Medications

- Donepezil > monitor for nausea, diarrhea and insomnia. test stools periodically for GI bleeding

- Rivastigmine > monitor for nausea, vomiting, abdominal pain and loss of appetite

- Memantine > monitor for hypertension, pain, headache, constipation, vomiting & fatigue

- Galantamine > monitor for dizziness, syncope, loss of appetite

  • Symptomatic treatments aimed at managing behaviors associated with cognitive decline.

Nursing Process in Dementia
Application #1: Assessment

  • Mental Status Examination Components:

    • Patient history often unreliable; focus on general appearance/motor behavior, mood, and thought processes.

Application #2: Continuing Assessment

  • Sensorium and Intellectual Processes:

    • Watch for confabulation, agnosia, and changes in self-concept reflecting sadness or loss.

Application #3: Data Analysis and Nursing Diagnoses

  • Outcomes and goals to be established based on individual assessments.

Application #4: Interventions

  • Treatment Focus: Identifying and addressing underlying conditions is essential for managing prognosis and quality of life.

Mental Health Promotion

  • Preventive Measures:

    • Research indicative of elevated levels of plasma homocysteine as a possible risk factor.

    • Engagement in brain-stimulating activities and maintaining an active social network may reduce risk, especially during midlife.

Community-Based Care for Dementia

  • Prevalence in Nursing Homes: A significant portion of residents, around half, are individuals with Alzheimer’s or other dementia-related conditions.

Self-Awareness Issues for Caregivers

  • Feelings of frustration and hopelessness may ensue from dealing with chronic conditions without clear restorative potential.

  • Discussion and support are vital for coping with emotional states related to dementia care.

Role of the Caregiver

  • Majority of caregivers are women (often daughters or wives), necessitating support and education on dementia care.

  • Support Needs:

    • Educational resources, emotional support, respite care, and assistance from support groups to promote personal balance and reduce strain.