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CHAPTER 14 – COGNITIVE DISORDERS

LEARNING OUTCOME 1
Discuss the biopsychosocial theories that explain delirium, dementia,
amnestic disorders, and other cognitive disorders.
CONCEPTS
1. Cognitive disorders include delirium, dementia, and amnestic disorders.
2. Delirium is caused by an underlying systemic illness. There are several types
of dementias that are classified as to the cause or area of brain damage.
Amnestic disorders are rare disorders caused by head trauma, hypoxia,
encephalitis, thiamine deficiency, and substance abuse.
3. There are multiple theories about the etiology of the various cognitive
disorders. Genetics appears to be linked to dementia of the Alzheimer’s type,
dementia from Huntington’s disease, and dementia from Pick’s disease.
Infection is linked to the cause of delirium, dementia from Creutzfeldt–Jakob
disease, Parkinson’s disease, and some amnestic disorders. In vascular
dementia, the brain tissue is destroyed by intermittent emboli that can range
from a few to over a dozen. Individual infarcts may vary by 1 cm in diameter.
Symptoms are commonly absent until 100 to 200 cc of brain tissue have been
destroyed. Underlying systemic illness or injury is often linked to the cause of
delirium and amnestic disorders.

LEARNING OUTCOME 2
Differentiate among the various types of cognitive disorders.
CONCEPTS
1. The distinguishing characteristics of delirium are an acute onset with
disruptions in thinking, perception, and memory. Dementia is a chronic
condition characterized by declines in multiple cognitive areas, including
memory. Amnestic disorders are uncommon cognitive disorder characterized
by amnesia.

LEARNING OUTCOME 3
Explain the differences between delirium, dementia, and depression.
CONCEPTS
1. Delirium is characterized by fluctuating levels of consciousness, varying
attentiveness, and an acute and rapid onset, and there is usually an
identifiable cause like underlying illness. The cognitive impairments in
delirium are generally reversible.
2. Dementia is characterized by stable levels of consciousness, steady
attentiveness, slow insidious onset, and undetermined cause. Dementia has a
chronic course and the cognitive impairments are generally not reversible.
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3. Sometimes affective disorders like depression can be masked by symptoms
suggesting dementia—disorientation, memory loss, distractibility, apathy,
difficulty in concentration, and inattentiveness. The term pseudodementia is
used to describe the reversible cognitive impairments seen in depression.
Pseudodementia is characterized by an abrupt onset, rapid clinical course,
and client complaints about cognitive failures. It is often not recognized in
older adults and must be differentiated from dementia. Treatment is
successful.

LEARNING OUTCOME 4
Compare possible assessment findings in delirium and dementia.
CONCEPTS
1. Assessment for delirium may identify fluctuating levels of consciousness,
disorientation, sundowning behaviors, impaired reasoning, and poor attention
span. There is an altered sleep–wake cycle with the client napping during the
day and being awake during the night. Motor activity will vary from stupor to
hyperactivity.
2. Assessment findings for dementia include memory impairment, aphasia,
apraxia, agnosia, poor judgment, and a decline in previous abilities. For a
client with dementia of the Alzheimer’s type, the symptoms will vary with the
stage of the illness.

LEARNING OUTCOME 5
Compare and contrast the nursing interventions and their rationales for
clients with delirium and dementia.
CONCEPTS
1. Interventions for delirium should focus on orientation efforts, appropriate
stimulation, and safety. Introduce self to client and call client by name at each
contact. Short-term memory loss causes confusion and frequent orientation is
needed. Maintain face-to-face contact to counteract distractions. Use short
concrete phrases because the client may not be able to process more
complex information. Keep the room well lit so environmental misperceptions
are reduced. Keep the environmental noise low so the client does not become
overstimulated. Set limits on aggressive and physically abusive behavior.
Clear limits are needed for the protection of staff and the client. One-to-one
staffing will provide safety and possibly limit the use of mechanical restraints.
2. Interventions for dementia should focus on gentle orientation efforts,
nutritional needs, elimination needs, supporting memory and safety. Gently
orient the client by directing him or her to familiar and pleasurable activities.
A client’s family in the home setting will need education about home safety
needs like precautions for wandering, MedicAlert® bracelets, effective door
locks, eliminating environmental hazards like throw rugs, installation of
handrails, labeling of rooms and drawers, decreasing the temperature on the
hot water heater, restricting driving, and taking knobs off of the oven and
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stove. It is important to maintain optimal nutrition through monitoring food

and fluid intake and providing nutrient-dense foods in finger-food form. The
client may need 1:1 assistance at meals and should be weighed regularly.
Bowel and bladder training will help control incontinence. Nonverbal forms of
communication will increase in significance as verbal communication skills
decrease. Structure the environment to support cognitive functions through
use of calendars, clocks, labels, and signs.

LEARNING OUTCOME 6
Incorporate psychiatric–mental health nursing strategies that support
optimal memory functioning in the care of clients with cognitive
disorders.
CONCEPTS
1. A client with dementia will benefit from an environment structured with
reminders like clocks, orientation boards, labels, and familiar pictures.
Reminiscence activities will provide an opportunity for the clients to talk.
Discussion should include likely social and historical events from the earlier
years of the client’s life. Because of the loss of episodic memory, triggers for
semantic memory are needed. These triggers should include a combination of
verbal and nonverbal cues, constant repetition, and the nurse’s consistent
tone, affect, and movements. Support cognitive strengths through providing
opportunities for the client to exercise them. Assist the client to cope with
cognitive deficits through use of adaptive techniques.

LEARNING OUTCOME 7
Identify the difficulties caregivers may face when working with clients
who have cognitive disorders.
CONCEPTS
1. Caring for clients with a diagnosis of a cognitive disorder can be difficult and
exhausting. Wandering behaviors create safety issues because of impaired
judgment. Sundowning disorientation can be difficult to manage if the client is
physically aggressive and assaultive. Families often need help with providing
ADLs and medication management. Home care is a way for nursing to address
the family needs while allowing the client to continue living at home. Nursing
can also provide education and explanation of symptoms and assist the family
in designing interventions. Because burnout and fatigue are common among
caregivers, counseling may be needed to cope with stress.
2. When a family member is diagnosed with dementia, there is a need for family
meetings. This forum will allow the family to discuss strategies for caring for
the client now and in the future. The family should also contact the
Alzheimer’s Disease and Related Disorders Association (ADRDA) as well as the
Alzheimer’s Association. Caregiver support groups can provide support and
information for caregivers. An attorney can address issues such as
competency, power of attorney, and distribution of the client’s assets. It will
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become necessary for the family to identify community resources that would
provide support like respite care. A MedicAlert® ID bracelet for the client will
assist with identification should the client wander off or become separated
from the caregiver.

LEARNING OUTCOME 8
Discuss the personal feelings and attitudes that are likely to interfere
with the psychiatric–mental health nurse’s ability to care for
cognitively impaired clients.
CONCEPTS
1. Caring for clients with cognitive disorders can be difficult and frustrating at
times. The client may not remember the caregiver or acknowledge the care
provided. The self-awareness inventory in the text is designed to increase
awareness of feelings and perceptions about working with clients with
cognitive disorders. An honest inventory of beliefs and values will help the
nurse become more successful in working with cognitively impaired clients
and their families.