1. Cognitive Responses & Organic Mental Disorders NUR 305

2. Cognitive responses Maladaptive cognitive responses include an inability to make decisions, impaired memory and judgment, disorientation, misperceptions, decreased attention span, and difficulties with logical reasoning.

3. Delirium Is the behavioral response to widespread disturbances in cerebral metabolism. Represents a sudden decline from a previous level of functioning. Is usually considered a medical emergency.

4. Delirium Should be considered any time there there is an acute change in mental status. Can occur at any age but advanced age is the greatest risk factor. Results in disturbances in consciousness, attention, cognition, perceptions, & motor ability. Commonly found in hospitalized patients; CCU, geriatric units, the ED, alcohol treatment units, & oncology units. May be related to systemic illness (i.e. systemic strep infection)

5. Delirium cont. The patient experiences a diminished awareness of the environment that involves sensory misperceptions and disordered thought and also experiences disturbances in psychomotor activity and the sleep-wake cycle.

6. Delirium cont. These disturbances develop rapidly (over hours to days) and fluctuate over the course of the day. Usually worsen at night.

7. Dementia A maladaptive cognitive response that features a loss of intellectual abilities and interferes with the patient’s usual social or occupational activities. Alzheimer’s disease (AD) is the most common type of dementia. AD accounts for 65% of all cases of dementia Affects 4.8 million people in the US

8. Comparison of delirium & dementia Delirium Onset: rapid ( hours to days) Course: wide fluctuations; may continue for weeks if cause is not found LOC: hyper-alert to difficult to arouse Orientation: disoriented;confused Attention: always impaired Sleep:always disturbed Dementia Onset: gradual (years) Course: slow but continuous decline LOC:normal Orientation:disoriented;confus ed Attention: may be intact; may focus on one thing for long periods Sleep: usually normal

9. Comparison of delirium & dementia cont. Delirium Behavior: agitated;restless Memory: especially recent memory impairment Cognition: disordered reasoning Thought content: incoherent, confused, delusional Perception: illusions, hallucinations Judgment: poor Insight: present in lucid moments Dementia Behavior: may be agitated or apathetic;may wonder Memory: especially recent memory impairment Cognition: disordered reasoning and calculation Perceptions: no change Judgment: poor;socially inappropriate Insight: absent

10. Depression and AD Depression associated with AD may be among the most common mood disorders of older adults. Pseudo-dementia is a cognitive impairment secondary to a functional psychiatric disorder such as depression, poor concentration, etc.

11. Early onset AD Early onset AD is associated with a more rapid course and genetic predisposition as compared with late-onset AD. An individual with one parent with early-onset AD has a 50% chance of developing it before the age of 55.

12. 3 stages of AD Stage 1: Mild Impaired memory Insidious loss in performing ADL’s Subtle personality changes Socially normal

13. Stages of AD cont. Stage II: Moderate Memory impairment Overt ADL impairment Behavior difficulties Variable social skills Supervision needed

14. Stages of AD cont. Stage III: Severe Fragmented memory No recognition of familiar people Assistance needed with basic ADL Fewer troublesome behaviors Reduced mobility

15. Predisposing factors related to impaired cognition Aging Neurobiological functioning (plaques and proteins in nerve cells and disruptions in cerebral blood supply. Changes in brain structures (cortical atrophy & ventricle enlargement) Genetic factors underlying psychiatric & medical conditions

16. Disorientation Disorientation is a common behavior related to dementia. Time orientation is affected first, then place, and finally person.

17. Confabulation Is a confused person’s tendency to make up a response to a question when he or she cannot remember the answer. Should not be viewed as lying or as an attempt to deceive but rather as a way of saving face in an embarrassing situation

18. AD progression Aphasia- difficulty finding the right word Apraxia- an inability to perform familiar skilled activities Agnosia-difficulty in recognizing well- known objects, including people Amnesia- significant memory impairment in the absence of clouded consciousness or other cognitive symptoms.

19. Disorientation Can result in fear and agitation when individuals have cognitive impairment. Behavior that becomes extremely agitated is called a catastrophic reaction and is a medical emergency

20. Predisposing Factors for AD Biological: Genetic predisposition: runs in families; genes have been identified Aging – risk factor for dementia associated with AD Neurobiological- neuronal plaques altered glial cells, twisted or tangled protein fibers in neurons. Alterations in neurotransmitter systems; in particular, a significant deficiency in acetylcholine. Disruptions in cerebral blood supply (vascular dementia) Dementia with Lewy bodies (DLB) neurofilaments assoc w/Parkinsons. In AD, 50-75% also have Lewy bodies.

21. Precipitating Stressors for Delirium -drug/substance use; polypharmacy -underlying medical conditions; CNS disorders, (head trauma; encephalitis) metabolic disorders, (hypothyroidism) poor nutrition with vitamin B deficiency, cardiopulmonary disorders, hypoxia, systemic illness & sensory deprivation or sensory overload.

22. Precipitating Stressors Associated with dementia: -depression -degenerative brain disorders;AD, Parkinson’s, Huntington’s disease -cerebrovascular dementia; multi-infarct dementia -toxic metabolic disturbances; alcoholism,poisons CNS infections; chronic meningitis, neurosyphilis

23. Brain imaging Positive Emission Tomography (PET), CT, & MRI Patients with early onset AD may show cortical atrophy, ventricular enlargement, and loss of temporal lobe volume, as well as marked loss in brain weight. Early and late onset AD show a pattern of frontal and temporal hypometabolism.

24. Coping mechanisms Associated with delirium: due to altered awareness with delirium, coping mechanisms are not generally used. Associated with dementia: include intellectualization, rationalization, denial, and regression, joking, depression, & withdrawal.

25. Primary NANDA Nursing Diagnoses Acute and chronic confusion Disturbed thought processes

26. DSM-IV-TR diagnoses Delirium Dementia Amnestic disorders (memory disorders)

27. Outcome The patient will achieve the optimum level of cognitive functioning.

28. Interventions related to delirium Caring for physiological needs (nutrition and fluid balance; IV therapy) Responding to hallucinations (protect patient from harm,orient back to reality) Therapeutic communication (simple, direct statements, clear messages) Patient education may need reinforcement

29. Interventions related to dementia Pharmacological approaches-cholinesterase inhibitors to increase levels of acetylcholine Orient the patient (clocks, calendars, newspaper) Therapeutic communication (empathy, respect; encourage reminiscence) Orient patient to surroundings (place a night light in the patient’s room.

30. Interventions related to dementia Reinforcement of positive coping mechanisms (staying active and socializing with others) Responding to wandering (observation and decrease stress in the environment Decreasing agitation (avoid power struggles, offer choices to patient) Family/community approaches address caregiver stress and respite care

31. Pharmacological Interventions related to dementia Cholinesterase inhibitors for AD: Aricept (Donepezil) Galantamine (Reminyl) Rivastigmine (Exelon)

32. Pharmacological approaches in AD cont. Antipsychotics for psychotic s/s Antidepressant for depressive s/s Benzodiazepines for anxiety/agitation Anticonvulsants for agitation, mood swings Serotonergic agents for psychosis. agitation