Neurocognitive Disorders Notes

Neurocognitive Disorders

Marjorie Shragher

Learning Outcomes

• Compare the different types of Neurocognitive disorders with predisposing factors, clinical manifestations, and assessments
• Identify Client Problems with interventions/implementation and educational topics for client and family
• Describe various treatment modalities including pharmacology for cognitive disorders
• Plan for discharge and identify the needs of the client &caregiver
• Evaluate the effectiveness of the implemented actions

Neurocognitive Disorders

• Deficit in cognition or memory
• Significant change from a previous level of functioning.
• The objective care
  • Provide dignity
  • Quality of life
  • Guidance and Support for caregivers.

Delirium

• Acute disturbance of cognition
• Short-term
• Abrupt
• Systemic illness or metabolic imbalance can cause a delay onset
• Duration is usually brief
• Subsides completely
• Recovery from underlying determinant
• Symptoms:
  • Confusion
  • Excitement
  • Disorientation
  • Clouding of consciousness.
  • Hallucinations and illusions

Delirium (Continued)

• Confusion
• Excitement
• Disorientation
• Clouding of consciousness.
• Hallucinations and illusions
• Recent memory impaired
• Sleep disturbances
• Restless to vegetative state
• Inattention
• Distractible
• Disorganized thinking
• Speech that is not norm
• Reasoning ability and goal-directed behavior
• Disorientation to time and place
• Emotional instability

Delirium - Autonomic Manifestations

• Tachycardia
• Sweating
• Flushed face
• Dilated pupils
• Elevated blood pressure

Delirium - Causes

• Due to Medical Condition
  • Infections, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, Malnutrition, pain, burns, social isolation, restraints, ICU admission, burns, heat stroke

Delirium - Substance-Induced

• May be caused by intoxication or withdrawal from certain substances, such as:
  • Anticholinergics, antihypertensives, corticosteroids, anticonvulsants, analgesics, and others
  • Alcohol, amphetamines, cannabis, cocaine, hallucinogens, inhalants, and others.
  • Toxins, including organic solvents and fuels, lead, mercury, arsenic, carbon monoxide, and others

Delirium - Types

• Substance Intoxication/Withdrawal Delirium
• Medication Induced
• Medical conditions

Neurocognitive Disorders (NCDs)

• Impairment in the cognitive functions of:
  • Thinking
  • Reasoning
  • Memory
  • Learning
  • Speaking
• Severity:
  • Mild or Major
• Dementia is major NCD

Primary vs. Secondary NCDs

• Primary NCDs:
  • The disorder itself is the major sign of some organic brain disease not directly related to any other organic illness (e.g., Alzheimer’s disease).
• Secondary NCDs:
  • Caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma).

NCD - Characteristics

• Impairment exists in abstract thinking, judgment, and impulse control
• Conventional rules of social conduct are disregarded
• Personal appearance and hygiene are neglected
• Language may or may not be affected.
• Personality change is common.

NCD - Temporary Dementia

• Reversible NCD
  • Stroke
  • Depression
  • Medication Side Effects
  • Nutritional deficiencies
  • Metabolic disorders

NCD - Cues

• Aphasia
• Apraxia
• Irritability
• Moody
• Outburst
• Wandering
• Incontinence
• Personal care problems
• Confabulation

Alzheimer's Disease (AD)

• Alzheimer’s disease (A D) accounts for 60% to 80% of all cases of N C D.
• Stages of A D
  • Stage 1: No apparent symptoms
  • Stage 2: Very mild change
  • Stage 3: Mild cognitive decline
  • Stage 4: Moderate cognitive decline
  • Stage 5: Moderately severe cognitive decline
  • Stage 6: Severe cognitive decline
  • Stage 7: Very severe cognitive decline

Alzheimer's - Etiologies

Etiologies may include:

• Neurotransmitter alterations
• Plaques and tangles
• Head trauma
• Genetic factors

Vascular Neurocognitive Disorder

• Progresses In steps
• Variable course
• Weakness
• Speech difficulty
• Gait small stepped
• Etiologies may include:
  • Hypertension
  • Cerebral emboli
  • Cerebral thrombosis

Frontotemporal Neurocognitive Disorder

• Shrinking of the frontal and temporal anterior lobes of the brain
• Previously called Pick’s disease
• Cause is unknown, may be genetic
• Behavioral and personality changes
• Speech and language problems

Neurocognitive Disorder Due to Traumatic Brain Injury

• Amnesia is the most common
• Repeated head trauma can lead to dementia pugilistica
• Symptoms
  • Emotional lability
  • Dysarthria
  • Ataxia
  • Impulsivity

Neurocognitive Disorder Due to Lewy Body Dementia

• Progresses more rapidly
• Appearance of Lewy bodies in the cerebral cortex and brainstem
• Progressive and irreversible
• May account for 25% of all NCD cases.
• Parkinson's feature
• Depression
• Delusions
• Visual

Neurocognitive Disorder Due to Parkinson’s

• 75% with PD have Dementia
• Caused by a loss of nerve cells located in the substantia nigra and a decrease in dopamine activity
• Cerebral changes in NCD due to Parkinson’s disease sometimes resemble those of AD

Neurocognitive Disorder Due to HIV

• Caused by brain infections with opportunistic organisms or by the HIV-1 virus directly
• Symptoms may range from barely perceptible changes to acute delirium to profound cognitive impairment.

Substance-Induced Neurocognitive Disorder

• Occurs as a result of reactions to, or the overuse or abuse of, substances such as:
  • Alcohol
  • Inhalants
  • Sedatives, hypnotics, and anxiolytics
  • Medications that cause anticholinergic side effects
  • Toxins : lead and mercury

Neurocognitive Disorder Due to Huntington’s

• Huntington’s disease is transmitted as a Mendelian dominant gene.
• Damage occurs in the areas of the basal ganglia and the cerebral cortex.
• The patient usually declines into a profound state of dementia and ataxia.
• Average course of the disease is based on age at onset, with juvenile- onset and late-onset having the shortest durations.

Neurocognitive Disorder Due to Prion Disease

• The disorder is attributable to prion disease
• Onset 40 and 60 years;
• Course is extremely rapid
• Progression from diagnosis to death in less than 2 years
• 5% to 15% of cases have a genetic component.

Neurocognitive Disorder Due to Other Conditions

• Hypothyroidism
• Hyperparathyroidism
• Pituitary insufficiency
• Uremia
• Encephalitis
• Brain tumor
• Pernicious anemia
• Thiamine deficiency
• Multiple sclerosis
• Pellagra (B3)
• Uncontrolled epilepsy
• Cardiopulmonary insufficiency
• Fluid and electrolyte imbalances
• Central nervous system and systemic infections
• Systemic lupus erythematosus

Nursing Process/Assessment - Patient History

• Areas of concern to be addressed:
  • Mood swings
  • Personality and behavioral changes
  • Catastrophic emotional reactions
  • Cognitive changes
  • Language difficulties
  • Orientation
  • Social Appropriateness
  • Current /past use of medications, drugs, and alcohol
  • Toxin exposure
• Patient and family history of specific illnesses

Biological and Exogenous Factors

• Biological Factors:
  • Hypoxia
  • Nutritional deficiencies
  • Metabolic disturbances:
  • Endocrine dysfunction:
  • Cardiovascular disease:
  • Primary brain disorders:
  • Infections:
  • Intracranial neoplasms
  • Congenital defects:
  • Birth trauma:
  • Cranial trauma:
• Exogenous Factors:
  • Volatile inhalant compounds
  • Heavy metals:
  • Other metallic elements: Aluminum
  • Organic phosphates:
  • Various insecticides
  • Substance abuse/dependence
  • Other medications:

Assessment - Recognizing Cues

• Physical assessment
• Neurological
• Sign of other disease
• Skin integrity
• Signs of Delirium
• Vitals
• Assess comfort
• Glasses and hearing aid
• Adequate nutrition and fluids
• Hallucinations

Pseudodementia vs. NCD

Diagnostic Laboratory Evaluations

blood and urine to test for:

• Various infections
• Hepatic and renal dysfunctions
• Diabetes or hypoglycemia
• Electrolyte imbalances
• Metabolic and endocrine disorders
• Nutritional deficiencies
• Presence of toxic substances

Diagnostic Procedures

• Electroencephalogram
• Computed tomography scan
• Positron emission tomography
• Magnetic resonance imaging
• Lumbar puncture to examine cerebrospinal fluid
• Amyloid PET scan techniques

Screening Tools

• Confusion Assessment Method (delirium)
• Neelon Champagne Confusion scale
• Functional dementia Scale
• Brief Interview for Mental Status
• Mini Mental Status Exam
• Functional Assessment Screening Tool
• Blessed Dementia Scale

Client Problems

• Risk for trauma
• Disturbed thought processes
• Impaired memory
• Disturbed sensory perception
• Risk for other-directed violence
• Impaired verbal communication
• Self-care deficit
• Situational low self-esteem
• Grieving
• Outcome Criteria
  • Has not experienced physical injury
  • Has not harmed self or others
  • Has maintained reality orientation to the best of his or her capability
  • Discusses positive aspects about self and life
  • Participates in activities of daily living with assistance

Patient/Family Education

• Management of the illness
• Ways to ensure patient safety
• How to maintain reality orientation
• Assistance with ADL
• Nutrition
• Behaviors
• Medication administration
• Hygiene and toileting
• Support Service

Intervention/Implementation - Delirium

• Determine/Treat underlying causes
• Staff to remain with patient at all times
• Monitor behavior and provide
• Reorientation and assurance.
• Room with low stimulus level
• Low-dose antipsychotic agents to relieve agitation and aggression
• Benzodiazepines commonly used when etiology is substance withdrawal

Intervention/Implementation - Communication

• Calm reassuring tone
• Positive worded sentence
• Do not argue
• Reinforce orientation
• Eye contact
• Short and simple
• Reminiscence and happy times
• Avoid confrontation
• Encourage family

Intervention/Implementation - General

• Minimize risk factors
• Recognize change quickly
• Protect from injury
• Promote dignity/quality of life
• Environmental safety
• Assess risk factors
• Hearing aid and Glasses
• Address hallucinations

Safety Issues

• Furniture arrangement
• Frequently used items easy access
• Bed low, siderails up (x3)
• Seizure precaution
• Near Nurses station
• Assist ambulate
• Cigarettes/lighter safety
• Frequent orientation
• Soft restraints (as needed)

Intervention/Implementation - Memory and Routine

• Memory aid
• Reorient
• Daily routine
• Consistent caregivers
• Remove mirror
• Physical activity in day
• Bathroom light

Intervention/Implementation - Environment

• Self Assessment
• Room closest to Nursing station
• Low stimuli
• Well lit
• Window
• ID bracelet, bed alarm, monitors
• Meds
• Assess for injury risk

Interventions/Implementation - Communication Techniques

• Speak in a calm voice
• Reinforce reality
• Reorient
• Introduce
• Eye contact
• Reminiscence
• Short time frames activities and instructions
• Approach front facing and slow
• Address by name
• Consistency in caregivers

Interventions for Self Care

• Identify abilities
• Allow Time
• Guidance
• Schedule
• Routine
• Ongoing assessments
• Caregiver support

Medications for Delirium

• Treat the underlying cause
• Antipsychotic (for agitation)
• Antianxiety (for anxiety/agitation, especially in substance withdrawal)
• Use caution - medication can cause delirium

Pharmacology - NCD

• Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes.
• Pharmaceutical agents for cognitive impairment:
  • Physostigmine (Antilirium)
  • Donepezil (Aricept)
  • Rivastigmine (Exelon)
  • Galantamine (Razadyne)
  • Memantine (Namenda)

Pharmacology - Cholinesterase Inhibitors

• Donepezil, Rivastigmine, Galantamine
• Increase acetylcholine at cholinergic synapses by inhibiting the breakdown acetylcholinesterase, which increased the availability of acetylcholine.
• Improves able to care for self
• Slows cognitive deterioration in mild to moderate stages of Alzheimer's

Pharmacology - Cholinesterase Inhibitors - Adverse Effects

• Adverse effects: GI: N/V/D:
  • Monitor
  • Promote fluid intake
  • Titrate dosages (Provider)
• Bradycardia, syncope
  • Monitor pulse rate at home
  • Screen for cardiac disease
• Contraindication: Caution with asthma of COPD.
• Aspirin: GI Bleed
• Meds that decrease therapeutic effects: Antihistamines, TCA, conventional antipsychotics

Pharmacology - Cholinesterase Inhibitors - Administration

• Start low, go slow
• Educate family
• Taper medication off (if discontinuing)
• Monitor for swallowing ability
• Administer Donepezil at Bedtime
• Rivastigmine take with food

Pharmacology - Memantine

• Moderate to severe Dementia
• Blocks the entry of calcium into nerve cells
• Slows done brain cell death
• Can use with cholinesterase inhibitors
• Monitor for Dizziness, headache, confusion and constipation

Pharmacology - Other Medications

• Antipsychotics (for behavioral symptoms)
• Antidepressants (for depression)
• Antianxiety (for anxiety)
• Sedatives (for sleep disturbances)

Alternative Complementary Therapies

• Fish Oil/Omega-3s
• Ginkgo. ​
• B-vitamins
• Curcumin
• Melatonin
• Mindfulness meditation class
• Caregiver education class
• Side Effects and Risks​
  • Don’t delay seeing a health care provider about memory loss.
  • Keep in mind that although many dietary supplements (and some prescription drugs) come from natural sources, “natural” does not always mean “safe.”​
  • Some dietary supplements have been found to interact with medications

Discharge Planning - Education

• Home environment assessment
• Wandering - strategies and safety
• Address and name display
• Potential to be Harmful to others - planning and prevention

Discharge Planning - Home Environment Safety

• Remove scatter rugs
• Water temperature control
• Stairs: handrails and mark steps with tape
• Adequate Lighting
• Clutter free environment
• Secure electrical cords
• Bathroom clutter free, with handrails
• Lock up cleaning supplies

Caregivers - Support

• Legal council information
• Educational needs as client declines (anticipatory guidance)
• Resources available as client declines
• Support, encourage to use help
• Encourage time for self - prevent burnout

Evaluation - Patient Outcomes

• Has the patient experienced injury?
• Does the patient maintain orientation to time, person, place, and situation to the best of their cognitive ability?
• Is the patient able to fulfill basic needs? Have those needs unmet by the patient been fulfilled by caregivers?
• Is confusion minimized by familiar objects and structured, routine schedule of activities?

Evaluation - Caregiver Preparedness

• Do the prospective caregivers have information regarding:
  • The progression of the illness
  • Where to go for assistance and support
  • How to promote the patient’s safety, minimize confusion and disorientation as well as how to cope with behaviors