1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 24 Cognitive Disorders

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview Cognition –Brain’s ability to process, retain, use information –Processes: reasoning, judgment, perception, attention, comprehension, memory Cognitive disorders: disruption or impairment in higher- level brain functions –Categories: delirium, dementia, amnestic disorders

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium Syndrome involving disturbance of consciousness with change in cognition Etiology: usually from identifiable physiologic, metabolic, cerebral disturbance or disease or from drug intoxication or withdrawal (see Box 24.1)

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium (cont.) Treatment and prognosis: transient; clearing with treatment of underlying cause –Psychopharmacology: sedation –Other medical treatments

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium and Nursing Process Application Assessment –History: medical history; medications (see Box 24.2) –General appearance, motor behavior: disturbed psychomotor behavior; possible speech problems –Mood, affect: rapid, unpredictable shifts –Thought processes, content

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium and Nursing Process Application (cont.) Assessment (cont.) –Sensorium, intellectual processes: altered LOC that fluctuates; attention deficits –Judgment, insight: impaired –Roles, relationships: inability to fulfill roles –Self-concept: fear, feelings of being threatened –Physiologic, self-care: sleep problems, failure to perceive internal body cues

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? There is usually an identifiable cause for the development of delirium.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Delirium is usually due to an identifiable physiologic, metabolic, or cerebral disturbance or disease or caused from drug intoxication or withdrawal.

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium and Nursing Process Application (cont.) Data analysis/nursing diagnoses –Risk for injury –Acute confusion Outcome identification –Freedom from injury –Increased orientation, reality contact

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium and Nursing Process Application (cont.) Intervention –Promoting patient safety –Managing patient’s confusion: orienting cues; speaking in low, clear voice; avoiding sensory overload –Promoting sleep, proper nutrition Evaluation

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Delirium and Community-Based Care Referrals for continued cognitive problems –Home health-care/visiting nurses –Rehabilitation program –Adult day care –Residential care –Support groups

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia Multiple cognitive deficits; primarily memory plus any of the following: –Aphasia (echolalia, palilalia) –Apraxia –Agnosia –Disturbance in executive function Differentiation from delirium (see Table 24.1)

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia (cont.) Onset, clinical course: –Stages Mild Moderate Severe Etiology: variable causes; decreased metabolic activity found postmortem

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia (cont.) Types of dementia: –Alzheimer’s disease –Vascular dementia –Pick’s disease –Creutzfeldt - Jakob disease –Parkinson’s disease –Huntington’s disease –Dementia due to head trauma

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia (cont.) Treatment and prognosis –Underlying cause –Usually progressive –Medications for degenerative dementias: cholinesterase inhibitors (see Table 24.2) –Symptomatic treatment for behaviors Antidepressants Antipsychotics (see Box 24.3) Mood stabilizers

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A patient with dementia experiences changes in his or her level of consciousness.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Patients with dementia do not typically experience altered levels of consciousness but do exhibit multiple cognitive deficits along with aphasia, apraxia, agnosia, or a disturbance in executive functioning.

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia and Nursing Process Application Assessment –Mental status exam –History –General appearance, motor behavior: apraxia, uninhibited behavior –Mood, affect: increasing labile mood; rapid shifting –Thought processes, content: impaired abstract thinking, delusions of persecution

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia and Nursing Process Application (cont.) Assessment (cont.) –Sensorium, intellectual processes: loss of intellectual function; memory deficits; confabulation –Judgment, insight: poor, limited –Self-concept –Roles, relationships –Physiologic, self-care: disturbed sleeping; incontinence, hygiene deficits

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia and Nursing Process Application (cont.) Data analysis/nursing diagnoses –Risk for injury –Chronic confusion Outcome identification –Freedom from injury –Involvement in surroundings, others in environment

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia and Nursing Process Application (cont.) Intervention –Safety –Sleep, proper nutrition, hygiene, activity –Environmental, routine structure –Emotional support (supportive touch) –Interaction, involvement (reminiscence therapy, distraction, time away, going along) Evaluation

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Dementia and Community-Based Care Many in community for most of their lives Family homes Adult day care centers Residential facilities Specialized Alzheimer’s units Referrals for programs, services

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mental Health Promotion Research to identify risk factors for dementia (elevated levels of plasma homocysteine) Measures to decrease risk for Alzheimer’s disease –Regular participation in brain-stimulating activities –Leisure-time physical activity during midlife –Participation with large social network

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A patient makes up answers to fill in memory gaps. The nurse identifies this as which of the following? –A. Echolalia –B. Palilalia –C. Aphasia –D. Confabulation

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Confabulation Rationale: Confabulation is the making up of answers to fill in gaps in the memory. –Echolalia is echoing or repeating what is heard; palilalia is repeating words or sounds over and over. Aphasia refers to a deterioration in language function.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Role of the Caregiver Majority: women (adult daughters or wives) 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

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Related Disorders Amnestic disorder: disturbance in memory due to physiologic effects of general medical condition or persisting effects of substance –Confusion, disorientation, attention deficits common –Lack multiple cognitive deficits seen in dementia –Treatment or removal of underlying medical cause → no further deterioration

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Inability to “teach” patient with dementia Feelings of frustration or hopelessness Knowledge that there is progressive deterioration until death, with no hope for improvement Importance of dignity for patient, family