Chapter 24: Cognitive Disorders

Key Terms:
Agnosia: inability to recognize or name objects despite intact sensory abilities
Alzheimers Disease: a progressive brain disorder that has a gradual onset but causes an increasing
decline in functioning, including loss of speech, loss of motor function, and profound personality and
behavioral changes such as those involving paranoia, delusions, hallucinations, inattention to hygiene,
and belligerence
Amnestic Disorder: disturbance in memory due to physiologic effects of general medical condition or
persisting effects of substances
Aphasia: deterioration of language function
Apraxia: impaired ability to execute motor function despite intact motor abilities
Confabulation: clients may make up answers to fill in memory gaps; usually associated with organic
brain problems
Creutzfeld-Jakob Disease: a central nervous system disorder that typically develops in adults 40 to 60
years of age and involves altered vision, loss or coordination or abnormal movements, and dementia
Delirium: a syndrome that involves a disturbance of consciousness accompanied by a change in
cognition
Dementia: a mental disorder that involves multiple cognitive deficits, initially involving memory
impairment with progressive deterioration that includes all cognitive functioning
Distraction: involves shifting the clients attention and energy to a different topic
Echolia: repetition or imitation of what someone elses says; echoing what is heard
Executive Functioning: the ability to think abstractly and to plan, initiate, sequence, monitor, and stop
complex behavior
Frontotemporal Lobar Degeneration: originally called Picks Disease
Going Along: technique used with clients with dementia; providing emotional reassurance to clients
without correcting their misconceptions of delusions
Huntingtons Disease: an inherited, dominant gene disease that primarily involves cerebral atrophy,
demyelination, and enlargement of brain ventricles
Korsakoffs Syndrome: type of dementia caused by long term, excessive alcohol intake that results in a
chronic thiamine or vitamin B deficiency
Kuru: prion disease, seen mainly in New Guinea from eating infected brain tissues
Lewy Body Disease: NCD with Lewy Bodies, Lewy Body Dementia; a disorder that involves
progressive cognitive impairment and extensive neuropsychiatric symptoms as well as motor symptoms
Neurocognitive Disorder (NCD): DSM-IV previously categorized adult cognitive disorders as dementia,
delirium, and amnesic disorders; re-conceptualized as NCD in DSM-5
Palilalia: repeating words or sounds over and over
Parkinsons Disease: a slowly progressive neurologic condition characterized by tremor, rigidity,
bradykinesia, and postural instability
Picks Disease: a degenerative brain disease that particularly affects the frontal and temporal lobes and
results in a clinical picture similar to Alzheimers Disease
Prion Disease: cause by a prion (a type of protein) that can trigger normal proteins in the brain to fold
abnormally
Reframing: cognitive behavioral technique in which alternative points of view are examined to explain
events
Reminiscence Therapy: thinking about or relating personally significant past experience in a purposeful
manner to benefit the client
Supportive Touch: the use of physical touch to convey support, interest, caring; may not be welcome or
effective with all clients
 Time Away: involves leaving clients for a sort period and then returning to them to reengage in
interaction; used in dementia care
Vascular Dementia: has symptoms similar to those of Alzheimers Disease, but onset is typically abrupt
and followed by rapid changes in functioning, a plateau or leveling-off period, and so on
Objectives:
Describe characteristics of and risk factors for cognitive disorders
o Cognition:
Brains ability to process, retain, use information
Processes: reasoning, judgment, perception, attention, comprehension, memory
o Cognitive Disorders: disruption or impairment in higher level brain functions
Can have devastating effects on ability to function in daily life
Can cause people to forget the names of immediate family members, be unable to
perform daily household tasks, and neglect personal hygiene
Categories: delirium, dementia, amnestic disorders
Distinguish between delirium and dementia in terms of symptoms, course, treatment, and prognosis
o Delirium:
Usually develops over a short period, sometimes a matter of hours, and fluctuates, or
changes, throughout the course of the day
Elderly are most frequently diagnosed
Risk Factors: increased severity of physical illness, older age, hearing impairment,
decreased food and fluid intake, medications, and baseline cognitive impairments seen in
dementia
Children: more susceptible, especially related to febrile illness or certain
medications such as anticholinergics
Etiology: usually from identifiable physiologic, metabolic, or cerebral disturbances or
disease or from drug intoxication or withdrawal
Most Common Causes Of Delirium Box 24.1 pg 468
Treatment and Prognosis: transient condition that clears with successful treatment of the
underlying cause
Psychopharmacology: some may show persistent or intermittent psychomotor
agitation, psychosis, and/or insomnia that can interfere with effective treatment or
pose a safety risk; sedation to prevent inadvertent self-injury may be indicated
o Haloperidol (Haldol): 0.5-1mg to decrease agitation and psychotic
symptoms, facilitate sleep
o Lorazepam(Ativan): helpful for sleep, but sedatives and long acting
benzos are avoided because they may worsen symptoms
o Exception: if delirium is induced by alcohol withdrawal, usually treated
with benzos
Other Medical Treatments: adequate food and fluid intake; IV fluids and TPN
may use as needed
o Dementia:
Involves multiple cognitive deficits, initially, memory impairments, and later the
following cognitive disturbances may be seen:
Aphasia (echolalia, palilalia)
Apraxia
Agnosia
Disturbance in executive function
If two diagnoses of delirium and dementia coexists, the symptoms of dementia remain
even when the delirium has cleared
Comparison of Delirium and Dementia Table 24.1 pg 475
Onset and Clinical Course:
 Mild: forgetfulness is the hallmark beginning
o Exceeds the normal, occasional forgetfulness experienced with aging
o Difficulty finding words, frequently loses objects, begins to experience
anxiety about losses
Moderate: confusion is apparent, along with progressive memory loss
o Can no longer perform complex tasks but remains oriented to person and
place
o Still recognizes familiar people
o End: person loses the ability to live independently and requires assistance
because of disorientation to time and loss of information such as address
and telephone number
Severe: personality and emotional changes occur
o Delusional, wanders at night, forgets the names of spouse and children,
requires assistance with ADLs
o Most live in nursing facilities
Etiology: variable causes; decreased metabolic activity; no definitive diagnosis can be
made until completion of postmortem examination
Genetic component identities for some as Huntingtons disease
Abnormal APOE is known to be linked with Alzheimers disease
Other causes are related to infections such as HIV and Creutzfeldt-Jackob disease
Types of Dementia:
o Alzheimers disease
o Vascular dementia
o Picks disease
o Creutzfeldt-Jakob disease
o Parkinsons disease
o Huntingtons disease
o Dementia due to head trauma
Treatment and Prognosis:
Underlying cause of dementia is identified so that treatment can be instituted
Prognosis for the progressive types of dementia may vary as described earlier, but
all prognoses involve progressive deterioration of physical and mental abilities
until death
Medications for degenerative dementias: cholinesterase inhibitors
o Drugs Used to Treat Dementia Table 24.2 pg 477
Symptomatic treatment for behaviors:
o Antidepressants: effects for significant depressive symptoms, can cause
delirium, SSRIs are used more often due to less side effects
o Antipsychotics:
Haloperidol (Haldol)
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
o Mood Stabilizers:
Lithium carbonate
Carbamazepine (Tegretol)
Valproic acid (Depakote)
Apply the nursing process to the care of clients with cognitive disorders
o Delirium:
Assessment:
History:
 o Medical history
o Medications
Drugs Causing Delirium Box 24.2 pg 469
General Appearance and Motor Behavior: disturbed psychomotor behavior,
possible speech problems
Mood and Affect: rapid, unpredictable shifts
Thought Process and Content:
o Difficult for nurses to assess these changes accurately and thoroughly
o Though Content: often unrelated to the situation, or speech is illogical and
difficult to understand
o Though Processes: disorganized and makes no sense, fragmented
o May exhibit delusions, believing that their altered sensory perceptions are
real
Sensorium and Intellectual Processes: altered LOC that fluctuates; attention
deficits
Judgment and Insight: impaired
Roles and Relationships: inability to fulfill roles
Self-Concept: fear, feelings of being threatened
Physiologic and Self-Care: sleep problems, failure to perceive internal body cues
Data Analysis/ Nursing Diagnoses:
Primary:
o Risk for Injury
o Acute Confusion
Additional:
o Disturbed Sensory Perception
o Disturbed Thought Process
o Disturbed Sleep Pattern
o Risk for deficient Fluid Volume
o Risk for Imbalanced Nutrition: Less than Body Requirements
Outcome Identification:
Client will be free of injury
Client will demonstrate increase orientation and reality contact
Client will maintain an adequate balance of activity and rest
Client will maintain adequate nutrition and fluid balance
Client will return to their optimal level of functioning
Interventions:
Promoting clients safety
o Teach the client to request assistance for activities (getting out of bed,
going to the bathroom)
o Provide close supervision to ensure safety during these activities
o Promptly respond to the clients call for assistance
Managing clients confusion
o Speak to client in a calm manner in a clear low voice; use simple
sentences
o Allow adequate time for the client to comprehend and respond
o Allow the client to make decisions as much as he/she is able to
o Provide orienting verbal cues when talking with the client
o Use supportive touch if appropriate
Controlling environment to reduce sensory overload
o Keep environmental noise to minimum (TV, radio)
 o Monitor the clients response to visitors; explain to family and friends that
the client may need to visit quietly one on one
o Validate the clients anxiety and fears, but do not reinforce
misconceptions
Promoting sleep and proper nutrition
o Monitor sleep and elimination patterns
o Monitor food and fluid intake; provide prompts or assistance to eat and
drink adequate amounts of foods and fluids
o Provide periodic assistance to bathroom if the client does not make
requests
o Discourage daytime napping to help sleep at night
o Encourage some exercise during day like sitting in a chair, walking in hall,
or other activities the client can manage
Evaluation: successful treatment of underlying causes and client returns to their previous
levels of functioning
o Dementia:
Assessment:
Mental Status Exam
History: interviews with family, friends or caregivers maybe necessary to obtain
data
General Appearance and Motor Behavior: apraxia, uninhibited behavior
(inappropriate jokes, neglecting personal hygiene, showing undue familiarity with
strangers, disregarding social conventions for acceptable behavior)
Mood and Affect: increasing labile mood; rapid shifting
Though Process and Content: impaired abstract thinking, delusions of persecution
Sensorium and Intellectual Processes: loss of intellectual function; memory
deficits; confabulation
Judgment and Insight: poor, limited
Self-Concept: may be angry or frustrated with self; lose awareness of self;
deteriorated till they cant recognize self
Role and Relationships: inadequate, unable to participate in meaningful
conversation, impaired
Physiologic and Self-Care: disturbed sleeping; incontinence, hygiene deficits
Data Analysis/ Nursing Diagnoses:
Risk for Injury
Disturbed Sleep Pattern
Risk for Deficient Fluid Volume
Risk for Imbalanced Nutrition: Less than Body Requirements
Chronic Confusion
Impaired Environmental Interpretation Syndrome
Impaired Memory
Impaired Social Interaction
Impaired Verbal Communication
Ineffective Role Performance
Outcome Identification:
Client will be free from injury
Client will maintain an adequate balance of activity and rest, nutrition, hydration
and elimination
Client will function as independently as possible given their limitations
Client will feel respected and supported
 Client will remain involved in their surroundings
Client will interact with other in the environment
Interventions:
Promoting clients safety and protecting from injury
o Offer unobtrusive assistance with or supervision of cooking, bathing, or
self-care activities
o Identify environmental triggers to help the client avoid them
Promoting adequate sleep, proper nutrition, and hygiene, and activity
o Prepare desirable foods and food the client can self-feed; sit with client
while eating
o Monitor bowel elimination patterns; intervene with fluids and fiber or
prompts
o Remind cline to urinate, provide pads or diapers as needed, checking and
changing them frequently to avoid infection, skin irritation and unpleasant
odors
o Encourage mild physical activity such as walking
Structuring environment and routine
o Encourage the client to follow regular routine and habits of bathing and
dressing rather than imposing new ones
o Monitor amount of environmental stimulation, and adjust when needed
Providing emotional support
o Be kind, respectful, calm, and reassuring; pay attention to the client
o Use supportive touch when appropriate
Promoting interaction with the client about the past
o Plan activities with clients interests and abilities
o Reminisce with the client about the past
o If the client is nonverbal, remain alert to nonverbal behavior
o Employ techniques of distraction, time away, going along, or reframing to
calm clients who are agitated, suspicious, or confused
Evaluation: treatment outcomes change constantly as disease progresses
Identify methods for meeting the needs of people who provide care for clients with dementia
o Majority: women (adult daughters or wives)
o Needs of Caregivers:
Education about dementia, care needed by patient
Assistance in dealing with own feelings of loss
Respite to care for own needs
Support groups
Assistance from agencies
Support to maintain personal life
Provide education to clients, families, caregivers, and community members to increase knowledge and
understanding of cognitive disorders
o Monitor chronic health conditions carefully
o Visit physician regularly
o Tell all physicians and health care providers what medications are taken, including OTC
medications, dietary supplements, and herbal preparations
o Check with physician before taking any nonprescription medication
o Avoid alcohol and recreational drugs
o Maintain a nutritious diet
o Get adequate sleep
o Use safety precautions when working with paint solvents, insecticides, and similar products
Evaluate your feelings, beliefs, and attitudes regarding clients with cognitive disorders
 o Inability to teach patients with dementia
o Feelings of frustration or hopelessness
o Knowledge that there is progressive deterioration until death, with no hope for improvement
o Importance of dignity for patient, family
Delirium and community-based care, dementia and community-based care, mental health promotion
o Delirium and Community-Based Care:
Referrals for continued cognitive problems
Home health-care/ visiting nurses
Rehabilitation program
Adult day care
Residential care
Support groups
o Dementia and Community-Based Care:
Many in community for most of their lives
Family homes
Adult day care centers
Residential facilities
Specialized Alzheimers units
Referrals for programs, services
o Mental Health Promotion:
Research to identify risk factors for dementia (elevated levels of plasma homocysteine)
Measures to decrease risk for Alzheimers disease
Regular participation in brain-stimulating activities
Leisure-time physical activity during midlife
Participation with large social network