1. Psychiatric / Mental Health Nursing Cognitive Disorders
West Coast University
NURS 204

2. What are cognitive disorders?
Delirium
Dementia
Amnestic disorders
Formerly know as organic mental disorder then it was renamed in DSM-IV-TR because of an incorrect implication that other mental disorders don’t have an organic cause.
Medical and substance abuse are the primary cause.

3. Etiology Delirium Dementia Amnestic disorders
An underlying systemic illness, including infection, and endocrine disorder, trauma, and drug/alcohol abuse
Dementia
Classified as to the cause or area of brain damage
Amnestic disorders
Head trauma, hypoxia, encephalitis, thiamine deficiency, and substance abuse

4. Theories Genetics Dementia of Alzheimer’s type
Dementia from Huntington’s disease
Dementia from Pick’s disease
Genetics in Alzheimer’s, huntington’s, and pick’s disease type
Alzheimer type: account to 50 to 70% of the cases. As many as†5.3 million Americans are living†with Alzheimerís disease.†Alzheimer's†destroys brain cells, causing memory loss and problems with†thinking and behavior severe enough to affect†work, lifelong hobbies or social life.†Alzheimerís gets worse over time, and it is fatal. Today it is the seventh-leading cause of death in the united states
Huntington's disease is a progressive, degenerative disease that causes certain nerve cells in your brain to waste away. Loss of nerve cells in the brain. As a result, you may experience uncontrolled movements, emotional disturbances and mental deterioration.Huntington's disease is an inherited disease. Signs and symptoms usually develop in middle age. Younger people with Huntington's disease often have a more severe case, and their symptoms may progress more quickly.
Frontotemporal dementia (FTD) describes a clinical syndrome associated with shrinking of the frontal and temporal anterior lobes of the brain. Originally known as Pickís disease,

5. Theories - continued Infection Vascular insufficiency
Delirium
Dementia from Creutzfeldt–Jakob disease
Parkinson’s disease
Amnestic disorders
Vascular insufficiency
Brain tissue destroyed
Symptoms absent until 100–200 cc of brain tissue destroyed
Underlying systemic illness or injury
Creutzfeldt-Jakob disease: Transmissible degenerative dementia caused by prions with rapid onset affecting the cerebral cortex through cell destruction and overgrowth
Classic Parkinson’s disease is unknown cause, another type has been linked from a previous viral infection in the brain

6. Differentiating Types of Cognitive Disorders
Delirium
Acute confusional state characterized by disruptions in thinking, perception, & memory
Dementia
Chronic state characterized by declines in multiple cognitive areas, including memory
Amnestic disorders
Uncommon cognitive disorder characterized by amnesia
Delirium: terrifying hallucinations and vivid dreams, a kalaidoscopic array of strange and absurd delusions, agitated behavior, inability to rest or sleep, tendency to convulse, urinary incontinence are common. Differentiating delirium and dementia can be a difficult process.

7. Amnestic Disorder Characterized by short-and long-term memory deficits
Inability to recall previously learned information or past events
Inability to learn new materials
Cofabulation, apathy, bland affect
Amnestic disorder NOS: not enough supporting evidence to link a cause to the amnesia (medical or substance)

8. Delirium and Dementia Differences
Fluctuating consciousness
Varying attentiveness
Acute
Rapid onset
Cause is identifiable
Generally reversible
Unable to diffrentiate from hallucination, dreams, illusions and imagery
Thinking is fragmented and disorganized unable to reason, judge, or solve problems
Impaired memory recall
Attention and wakefulness is impaired. Wakefulness is reduced during the day. Then restlessness, and agitation at night

9. Delirium and Dementia Differences - continued
Stable levels of consciousness
Steady attentiveness
Chronic
Slow insidious onset
Undetermined cause
Generally irreversible
Stable levels of consciousness Until terminal stages
Insidious : gradual

10. Depression Depression can be masked by symptoms suggestive of dementia
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

11. Assessment Delirium Fluctuating levels of consciousness
Disorientation and sundowning
Impaired reasoning
Poor attention span
Altered sleep–wake cycle
Alternating patterns of motor behavior

12. Assessment - continued
Dementia
Memory impairment
Cognitive impairment
Aphasia
Apraxia
Agnosia
Poor judgment
Decline in previous abilities
Apraxia: Loss of language ability with difficulty finding words and naming objects
Apraxia is a neurological disorder characterized by loss of the ability to execute or carry out learned purposeful movements, despite having the desire and the physical ability to perform the movements.
Agnosia: The inability to recognize and identify objects or persons despite having knowledge of the characteristics of those objects or persons. People with agnosia may have difficulty recognizing the geometric features of an object or face or may be able to perceive the geometric features but not know what the object is used for or whether a face is familiar or not. Agnosia can be limited to one sensory modality such as vision or hearing. For example, a person may have difficulty in recognizing an object as a cup or identifying a sound as a cough

13. Interventions for Delirium
Introduce self and call client by name at each contact
Maintain face-to-face contact
Use short, concrete phrases
Keep room well lit
Keep environmental noise low
Set limits on behavior
1:1 staffing as needed

14. Interventions for Dementia
Gently orient the client
Educate family about home safety
Maintain optimal nutrition
Bowel and bladder training
Utilize nonverbal forms of communication
Structure the environment to support cognitive functions

15. Supporting Optimal Memory Functioning
Environmental reminders
Reminiscence activities
Triggers for semantic memory
Support cognitive strengths
Assist to cope with cognitive deficits

16. Common Medications for Cognitive Disorders
Dementia of the Alzheimer’s Type (DAT)
Donepezil (Aricept)
Galantamine (Reminyl)
Rivastignime (Exelon)
Slows the rate of cognitive decline
Potent acetylcholinesterase inhibitors

17. Common Medications for Cognitive Disorders
Dementia with Lewy Bodies
Escitalopram (Lexapro)
Reduce symptoms of depression when present
Pick’s Disease
Valproic Acid (Depakote)
Reduce problematic mood swings and agitated behavior
Vascular Dementia with psychosis
Quetiapine (Seroquel)
Reduce or eliminate delusions and hallucination

18. Caregiver Difficulties
Wandering behaviors
Sundowning disorientation
ADLs
Medication management
Burnout and fatigue

19. Caregiver Resources Family meetings
Alzheimer’s Disease and Related Disorders Association (ADRDA)
Caregiver support groups
Identify community resources
ID bracelet for the client

20. Self-Awareness
Caring for clients with cognitive disorders can be difficult and frustrating at times.
Self-awareness inventory in your text
The responses are designed to help you to become more successful in working with cognitively impaired clients and their families.

21. Review Question Delirium is thought to be caused primarily by:
A. Genetics.
B. Underlying systemic illness.
C. Brain injury.
D. Vascular insufficiency.
Answer #2 is correct. Delirium is usually caused by an underlying systemic illness such as dehydration, diabetes, hyponatremia, hypercalcemia, thyroid crisis, infection, silent myocardial infarction, drug intoxication, or liver or renal failure. If the cause is removed quickly, complete recovery from delirium can be achieved.

22. Review Question A key characteristic of an amnestic disorder is:
A. Short-term and long-term memory loss.
B. Hallucinations.
C. Long-term memory loss.
D. Short-term memory loss.
Answer #1 is correct. An amnestic disorder is characterized by both short-term and long-term memory deficits, an inability to recall previously learned information and past events, inability to learn new material, confabulation, apathy, and a bland affect.

23. Review Question
A caregiver for a client diagnosed with dementia of the Alzheimer’s type is unable to effectively communicate with the client. Which of the following techniques would be most appropriate to teach the caregiver?
A. Setting strict time limits and rephrasing misunderstood questions
B. Using multiple memory cues and giving several directions at once
C. Correcting errors by the client, and speaking in a loud clear voiced.
D. Encouraging verbal and nonverbal communication, while maintaining a calm demeanor
Answer D is correct. It is important to teach the caregiver that as verbal communication skills decline, nonverbal communication will become more prominent.

24. Review Question
The home health nurse is instructing a family who cares for a patient with dementia alzheimer’s type about safety measure would include:
A. Putting locks on the outside of doors so the patient can not leave the room or house
B. Purchasing a MedicAlert bracelet that identifies the client as having DAT
C. Chemically restraining the patient to prevent agitation and confusion
D. Restraining the patient in a chair or bed to prevent falls

25. Review Question
The actual cause of dementia associated with dementia of the Alzheimer’s Type is:
A. Diabetes
B. Infection
C. Unknown
D. Head trauma
E. Drug intoxication c.

26. Review Question
One of the difference between delirium and dementia is that clients with delirium:
A. Are very attentive
B. Experience a slow, insidious onset of symptoms
C. Have fluctuating consciousness
D. Respond to questions appropriately and correctly