1. Copyright © 2014. F.A. Davis Company Neurocognitive Disorders Chapter 22

2. Copyright © 2014. F.A. Davis Company Introduction Neurocognitive disorders are disorders in which a clinically significant deficit in cognition or memory exists representing a significant change from a previous level of functioning.

3. Copyright © 2014. F.A. Davis Company The number of people with neurocognitive disorder is growing because more people now survive into the high-risk period for the disorder, which is age 65 and beyond. Introduction (cont.)

4. Copyright © 2014. F.A. Davis Company Delirium Delirium is characterized by a disturbance in level of awareness and a change in cognition that develops rapidly over a short period.

5. Copyright © 2014. F.A. Davis Company Symptoms – Difficulty sustaining and shifting attention – Extreme distractibility – Disorganized thinking – Speech that is rambling, irrelevant, pressured, and incoherent – Impaired reasoning ability and goal-directed behavior – Disorientation to time and place Delirium (cont.)

6. Copyright © 2014. F.A. Davis Company Symptoms (cont.) – Impairment of recent memory – Misperceptions about the environment, including illusions and hallucinations – Disturbance in level of consciousness, with interruption of the sleep-wake cycle – Psychomotor activity that fluctuates between agitation and restlessness and a vegetative state – Emotional instability Delirium (cont.)

7. Copyright © 2014. F.A. Davis Company Symptoms include autonomic manifestations such as: – Tachycardia – Sweating – Flushed face – Dilated pupils – Elevated blood pressure Delirium (cont.)

8. Copyright © 2014. F.A. Davis Company Usually begins abruptly Can have a slower onset if underlying etiology is systemic illness or metabolic imbalance Duration is usually brief and subsides completely on recovery from underlying determinant Delirium (cont.)

9. Copyright © 2014. F.A. Davis Company Predisposing Factors Delirium Due to a General Medical Condition – Examples Infections, febrile illness, metabolic disorders, head trauma, seizures, migraine headaches, brain abscess, stroke, electrolyte imbalance, others

10. Copyright © 2014. F.A. Davis Company Substance-Induced Delirium – 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 Predisposing Factors (cont.)

11. Copyright © 2014. F.A. Davis Company Neurocognitive Disorder Impairment in the cognitive functions of thinking, reasoning, memory, learning, and speaking

12. Copyright © 2014. F.A. Davis Company Neurocognitive disorder (NCD) may be classified as mild or major, depending on severity of symptoms. Mild NCD has also been called mild cognitive impairment. Major NCD constitutes what was previously described in the DSM as dementia. Neurocognitive Disorder (cont.)

13. Copyright © 2014. F.A. Davis Company Primary NCDs are those in which 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 are caused by or related to another disease or condition (e.g., HIV disease or cerebral trauma) Neurocognitive Disorder (cont.)

14. Copyright © 2014. F.A. Davis Company Symptoms – Impairment exists in abstract thinking, judgment, and impulse control. – Conventional rules of social conduct are disregarded. – Personal appearance and hygiene are neglected. Neurocognitive Disorder (cont.)

15. Copyright © 2014. F.A. Davis Company Symptoms (cont.) – Language may or may not be affected. – Personality change is common. Neurocognitive Disorder (cont.)

16. Copyright © 2014. F.A. Davis Company Reversible NCD may be more appropriately termed temporary. It can occur as a result of: – Stroke – Depression – Side effects of medications – Nutritional deficiencies – Metabolic disorders Neurocognitive Disorder (cont.)

17. Copyright © 2014. F.A. Davis Company As the disease progresses, symptoms may include: – Aphasia – Apraxia – Irritability and moodiness, with sudden outbursts over trivial issues – Inability to care for personal needs independently – Wandering away from the home – Incontinence Neurocognitive Disorder (cont.)

18. Copyright © 2014. F.A. Davis Company Alzheimer’s disease (AD) accounts for 50 to 60 percent of all cases of NCD. – AD can be described in stages: Stage 1. No apparent symptoms Stage 2. Forgetfulness Stage 3. Mild cognitive decline Neurocognitive Disorder (cont.)

19. Copyright © 2014. F.A. Davis Company – Stages of Alzheimer’s disease (cont.): Stage 4. Mild-to-moderate cognitive decline Stage 5. Moderate cognitive decline Stage 6. Moderate-to-severe cognitive decline Stage 7. Severe cognitive decline Neurocognitive Disorder (cont.)

20. Copyright © 2014. F.A. Davis Company 1.Hospitalized and diagnosed in the fourth stage of NCD due to Alzheimer’s disease, a client, when asked about the previous evening, describes a wonderful evening spent on a cruise. Which symptom is the client exhibiting? A.Aphasia B.Confabulation C.Delirium D.Apraxia Neurocognitive Disorder (cont.)

21. Copyright © 2014. F.A. Davis Company Correct answer: B – Confabulation is a behavioral reaction to memory loss in which the client fills in memory gaps with information about events that have not occurred. During the fourth stage of Alzheimer’s dementia, a client will use confabulation in an effort to maintain self-esteem. Neurocognitive Disorder (cont.)

22. Copyright © 2014. F.A. Davis Company Predisposing Factors NCD Due to Alzheimer’s Disease – Onset is slow and insidious. – Course of the disorder is generally progressive and deteriorating.

23. Copyright © 2014. F.A. Davis Company NCD Due to Alzheimer’s Disease (cont.) – Etiologies may include: Acetylcholine alterations Plaques and Tangles Head trauma Genetic factors Predisposing Factors (cont.)

24. Copyright © 2014. F.A. Davis Company 2.A client is newly diagnosed with second stage NCD due to Alzheimer’s disease. Which cognitive change would a nurse observe? A.Memory disturbance B.Confabulation C.Apraxia D.Inability to plan or organize Predisposing Factors (cont.)

25. Copyright © 2014. F.A. Davis Company Correct answer: A – In the second stage of the illness, losses in short- term memory are common and the individual may begin to lose things or forget names of people. It’s at this stage that a diagnosis may be considered. Predisposing Factors (cont.)

26. Copyright © 2014. F.A. Davis Company Vascular NCD – NCD occurs as a result of significant cerebrovascular disease. – There is a more abrupt onset than is seen in association with Alzheimer’s disease, and the course is more variable. Predisposing Factors (cont.)

27. Copyright © 2014. F.A. Davis Company Vascular NCD (cont.) – Etiologies may include: Hypertension Cerebral emboli Cerebral thrombosis Predisposing Factors (cont.)

28. Copyright © 2014. F.A. Davis Company Frontotemporal NCD – Occurs as a result of shrinking of the frontal and temporal anterior lobes of the brain – Previously called Pick’s disease – Exact cause is unknown, but genetics appears to be a factor Predisposing Factors (cont.)

29. Copyright © 2014. F.A. Davis Company NCD Due to Traumatic Brain Injury – Amnesia is the most common neurobehavioral symptom following head trauma. – Repeated head trauma can result in dementia pugilistica with symptoms of: – Emotional liability – Dysarthria – Ataxia – Impulsivity Predisposing Factors (cont.)

30. Copyright © 2014. F.A. Davis Company NCD Due to Lewy Body Disease – Similar to Alzheimer’s disease, but progresses more rapidly – Appearance of Lewy bodies in the cerebral cortex and brainstem – Progressive and irreversible – May account for 25 percent of all NCD cases Predisposing Factors (cont.)

31. Copyright © 2014. F.A. Davis Company NCD Due to Parkinson’s Disease – This is 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 Alzheimer’s disease. Predisposing Factors (cont.)

32. Copyright © 2014. F.A. Davis Company NCD Due to HIV Infection – 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. Predisposing Factors (cont.)

33. Copyright © 2014. F.A. Davis Company Substance-Induced NCD – 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 site effects Toxins, such as lead and mercury Predisposing Factors (cont.)

34. Copyright © 2014. F.A. Davis Company NCD Due to Huntington’s Disease – This disease is transmitted as a Mendelian dominant gene. – Damage occurs in the areas of the basal ganglia and the cerebral cortex. – The client usually declines into a profound state of cognitive impairment and ataxia. – Average course of the disease is based on age at onset, with juvenile-onset and late-onset having the shortest duration. Predisposing Factors (cont.)

35. Copyright © 2014. F.A. Davis Company NCD Due to Prion Disease – The disorder is attributable to prion disease (e.g., Creutzfeldt-Jakob disease or bovine spongiform encephalopathy). – Onset of symptoms typically occurs between ages 40 and 60 years; course is extremely rapid with progression from diagnosis to death in less than 2 years. – Five to 15 percent of cases have a genetic component. Predisposing Factors (cont.)

36. Copyright © 2014. F.A. Davis Company NCD Due to Another Medical Condition ‒Hypothyroidism ‒Hyperparathyroidism ‒Pituitary insufficiency ‒Uremia ‒Encephalitis ‒Brain tumor ‒Pernicious anemia ‒Thiamine deficiency ‒Multiple sclerosis ‒Pellagra ‒Uncontrolled epilepsy ‒Cardiopulmonary insufficiency ‒Fluid and electrolyte imbalances ‒CNS and systemic infections ‒Systemic lupus erythematosus Predisposing Factors (cont.)

37. Copyright © 2014. F.A. Davis Company 3.Which statement is true about vascular NCD? A.Vascular NCD is reversible. B.Vascular NCD is characterized by plaques and tangles in the brain. C.Vascular NCD involves a gradual, progressive cognitive deterioration. D.Vascular NCD involves a variable pattern of cognitive functioning. Predisposing Factors (cont.)

38. Copyright © 2014. F.A. Davis Company Correct answer: D – In vascular NCD, clients suffer the equivalent of small strokes that destroy many areas of the brain. The pattern of deficits is variable, depending on which regions of the brain have been affected. Predisposing Factors (cont.)

39. Copyright © 2014. F.A. Davis Company Application of the Nursing Process/Assessment The Client History – Areas of concern to be addressed: Type, frequency, and severity of mood swings Personality and behavioral changes Catastrophic emotional reactions Cognitive changes Language difficulties

40. Copyright © 2014. F.A. Davis Company The Client History (cont.) – Areas of concern to be addressed (cont.) Orientation to person, place, time, and situation Appropriateness of social behavior Current and past use of medications, drugs, and alcohol Possible exposure to toxins Client and family history of specific illnesses Application of the Nursing Process/Assessment (cont.)

41. Copyright © 2014. F.A. Davis Company Physical Assessment – Assessment for diseases of various organ systems that can induce confusion, loss of memory, and behavioral changes Application of the Nursing Process/Assessment (cont.)

42. Copyright © 2014. F.A. Davis Company Physical Assessment (cont.) – Neurological examination to assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination Application of the Nursing Process/Assessment (cont.)

43. Copyright © 2014. F.A. Davis Company Physical Assessment (cont.) – Psychological tests to differentiate between NCD and pseudodementia (depression) Application of the Nursing Process/Assessment (cont.)

44. Copyright © 2014. F.A. Davis Company Diagnostic Laboratory Evaluations – Include blood and urine to test for the following: Various infections Hepatic and renal dysfunctions Diabetes or hypoglycemia Electrolyte imbalances Metabolic and endocrine disorders Nutritional deficiencies Presence of toxic substances Application of the Nursing Process/Assessment (cont.)

45. Copyright © 2014. F.A. Davis Company Other diagnostic evaluations may include: – Electroencephalogram (EEG) – Computed tomography (CT) scan – Positron emission tomography (PET) – Magnetic resonance imaging (MRI) – Lumbar puncture to examine cerebrospinal fluid (CSF) Application of the Nursing Process/Assessment (cont.)

46. Copyright © 2014. F.A. Davis Company Nursing Diagnosis/Outcome Identification 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

47. Copyright © 2014. F.A. Davis Company Outcome Criteria The Client: – 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.

48. Copyright © 2014. F.A. Davis Company Planning/Implementation Care plan for the client with a cognitive disorder is aimed at: – Protection of self and others – Maintaining orientation to reality to the best of client’s ability – Minimizing confusion – Fulfilling basic needs – Assisting and educating prospective caregivers about appropriate care for the client

49. Copyright © 2014. F.A. Davis Company Client/Family Education Nature of the Illness – Possible causes – What to expect – Symptoms

50. Copyright © 2014. F.A. Davis Company Management of the Illness – Ways to ensure client safety – How to maintain reality orientation – Provide assistance with activities of daily living – Nutritional information – Difficult behaviors – Medication administration – Matters related to hygiene and toileting Client/Family Education (cont.)

51. Copyright © 2014. F.A. Davis Company Support Services – Financial assistance – Legal assistance – Caregiver support groups – Respite care – Home health care Client/Family Education (cont.)

52. Copyright © 2014. F.A. Davis Company Nursing Process: Evaluation Based on the accomplishment of outcome criteria

53. Copyright © 2014. F.A. Davis Company Medical Treatment Modalities Delirium – Determination and correction of the underlying causes – Staff to remain with client at all times to monitor behavior and provide reorientation and assurance

54. Copyright © 2014. F.A. Davis Company Delirium (cont.) – Room with low stimulus level – Low-dose antipsychotic agents to relieve agitation and aggression – Benzodiazepines commonly used when etiology is substance withdrawal Medical Treatment Modalities (cont.)

55. Copyright © 2014. F.A. Davis Company NCD – Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes. Medical Treatment Modalities (cont.)

56. Copyright © 2014. F.A. Davis Company NCD (cont.) – Pharmaceutical agents For cognitive impairment: – Physostigmine (Antilirium) – Donepezil (Aricept) – Rivastigmine (Exelon) – Galantamine (Razadyne) – Memantine (Namenda) Medical Treatment Modalities (cont.)

57. Copyright © 2014. F.A. Davis Company – Pharmaceutical agents for NCDs (cont.) For agitation, aggression, hallucinations, thought disturbances, and wandering: – Risperidone (Risperdal) – Olanzapine (Zyprexa) – Quetiapine (Seroquel) – Ziprasidone (Geodon) – These drugs cause fewer anticholinergic and EPS than older antipsychotics. – They carry a black-box warning that all antipsychotics are associated with an increased risk of death in elderly patients with NCD. Medical Treatment Modalities (cont.)

58. Copyright © 2014. F.A. Davis Company ‒Pharmaceutical agents for NCDs (cont.) For agitation, aggression, hallucinations, thought disturbances, and wandering (cont.): – Haloperidol (Haldol) Still commonly used because of its proven efficacy Higher potential for anticholinergic, EPS, and sedative effects than with the atypical antipsychotics Carries black-box warning that it is associated with increased risk of death in elderly patients with NCD Medical Treatment Modalities (cont.)

59. Copyright © 2014. F.A. Davis Company 4.A client has recently been diagnosed with mild to moderate NCD due to Alzheimer’s disease. Which medication would the nurse expect the physician to order for this client’s cognitive impairment? A.Nortriptyline (Pamelor) B. Zaleplon (Sonata) C.Donepezil (Aricept) D.Quetiapine (Seroquel) Medical Treatment Modalities (cont.)

60. Copyright © 2014. F.A. Davis Company Correct answer: C – Donepezil is used to improve cognition in clients diagnosed with mild to moderate dementia associated with Alzheimer’s disease. Its action improves cholinergic function by inhibiting acetylcholinesterase. Medical Treatment Modalities (cont.)

61. Copyright © 2014. F.A. Davis Company ‒Pharmaceutical agents for NCDs (cont.) For depression: – SSRIs Often considered first line due to favorable side effect profile – Tricyclic antidepressants Often avoided due to anticholinergic and cardiac side effects – Trazodone (Desyrel) Good choice for clients with insomnia – Dopaminergic agents Helpful in treatment of severe apathy Medical Treatment Modalities (cont.)

62. Copyright © 2014. F.A. Davis Company ‒Pharmaceutical agents for NCDs (cont.) For anxiety (should not be used routinely for prolonged periods): – Chlordiazepoxide (Librium) – Alprazolam (Xanax) – Lorazepam (Ativan) – Oxazepam (Serax) – Diazepam (Valium) Medical Treatment Modalities (cont.)

63. Copyright © 2014. F.A. Davis Company ‒Pharmaceutical agents for NCDs (cont.) For sleep disturbances (for short-term therapy only): – Flurazepam (Dalmane) – Temazepam (Restoril) – Triazolam (Halcion) – Zolpidem (Ambien) – Zaleplon (Sonata) – Ramelteon (Rozerem) – Eszopiclone (Lunesta) – Trazodone (Desyrel) – Mirtazapine (Remeron) Medical Treatment Modalities (cont.)

64. Copyright © 2014. F.A. Davis Company ‒Pharmaceutical agents for NCDs (cont.) Dosage adjustments with regard to physiological changes in aging clients must be made with all medications. Medical Treatment Modalities (cont.)