1. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. CHAPTER 17 Cognitive Disorders 1

2. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Etiology  Delirium  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 2

3. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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 3

4. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Delirium – Clinical Picture Disturbances in consciousnessDisturbances in consciousness Change in cognitionChange in cognition Develops over a short period of timeDevelops over a short period of time Common in hospitalized patients, especially older adultsCommon in hospitalized patients, especially older adults Always secondary to another physiological conditionAlways secondary to another physiological condition Is a transient disorderIs a transient disorder If underlying condition corrected, complete recovery should occurIf underlying condition corrected, complete recovery should occur

5. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5 Delirium Assessment Four cardinal featuresFour cardinal features –Acute onset and fluctuating course –Inattention –Disorganized thinking –Disturbance of consciousness

6. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Delirium Assessment Cognitive and perceptual disturbancesCognitive and perceptual disturbances –Illusions –Hallucinations Physical needsPhysical needs Mood and physical behaviorsMood and physical behaviors Attention spanAttention span ReasoningReasoning Sleep and wake cycleSleep and wake cycle

7. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 Delirium Nursing Diagnoses Risk for injuryRisk for injury Acute confusionAcute confusion Deficient fluid volumeDeficient fluid volume Insomnia, Sleep deprivationInsomnia, Sleep deprivation Impaired verbal communicationImpaired verbal communication FearFear Self-care deficitSelf-care deficit Disturbed thought processDisturbed thought process

8. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Delirium Outcomes Identification Patient will return to premorbid level of functioning.Patient will return to premorbid level of functioning. Patient will remain safe and free from injury while in the hospital.Patient will remain safe and free from injury while in the hospital. Patient will be oriented to time, place, and person.Patient will be oriented to time, place, and person. Patient will be free from falls and injury.Patient will be free from falls and injury.

9. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9 Delirium Implementation Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance.Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance. Perform comprehensive nursing assessment to aid in identifying cause.Perform comprehensive nursing assessment to aid in identifying cause. Assist with proper health management to eradicate underlying cause.Assist with proper health management to eradicate underlying cause. Use supportive measures to relieve distress.Use supportive measures to relieve distress.

10. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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 10

11. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11 Delirium Evaluation Patient will remain safe.Patient will remain safe. Patient will be oriented to time, place, and person by discharge.Patient will be oriented to time, place, and person by discharge. Underlying cause will be treated and ameliorated.Underlying cause will be treated and ameliorated.

12. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 Dementia Progressive deterioration of cognitive functioning and global impairment of intellectProgressive deterioration of cognitive functioning and global impairment of intellect No change in consciousnessNo change in consciousness Difficulty with memory, thinking, and comprehensionDifficulty with memory, thinking, and comprehension Majority of dementias are irreversibleMajority of dementias are irreversible

13. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13 Dementia Primary Versus Secondary PrimaryPrimary –Irreversible –Progressive –Not secondary to any other disease –Example: Alzheimer's disease SecondarySecondary –Result of some other pathological process –Example: AIDS-related dementia

14. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14 Alzheimer’s Disease Etiology Biological factorsBiological factors –Cerebral atrophy –Neurofibrillary tangles –Neuritic plaques GeneticGenetic  Dementia of Alzheimer’s type  Dementia from Huntington’s disease  Dementia from Pick’s disease

15. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Alzheimer’s Disease Etiology Environmental factorEnvironmental factor Dementia from Creutzfeldt–Jakob diseaseDementia from Creutzfeldt–Jakob disease 15

16. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 Nursing Process AssessmentAssessment –Confabulation –Perseveration Cardinal symptoms observed in ADCardinal symptoms observed in AD –Amnesia or memory impairment –Aphasia –Apraxia –Agnosia –Disturbances in executive functioning

17. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Nursing Process  Poor judgment  Decline in previous abilities 17

18. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18 Stages of Alzheimer's Disease Stage 1 (Mild) – forgetfulnessStage 1 (Mild) – forgetfulness Stage 2 (Moderate) – confusionStage 2 (Moderate) – confusion Stage 3 (Moderate to Severe) – unable to identify familiar objects or peopleStage 3 (Moderate to Severe) – unable to identify familiar objects or people Stage 4 (Late) – end-stageStage 4 (Late) – end-stage

19. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Alzheimer’s Disease Nursing Diagnoses Risk for injuryRisk for injury Impaired verbal communicationImpaired verbal communication Impaired environmental interpretation syndromeImpaired environmental interpretation syndrome Impaired memoryImpaired memory ConfusionConfusion Caregiver role strainCaregiver role strain

20. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20 Alzheimer's Disease Outcomes Identification Areas to targetAreas to target –Injury –Communication –Agitation level –Caregiver role strain –Impaired environmental interpretation: chronic confusion –Self-care needs

21. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21 Alzheimer's Disease Planning Geared towards person’s immediate needsGeared towards person’s immediate needs Identify level of functioningIdentify level of functioning Assess caregivers’ needsAssess caregivers’ needs Plan and identify appropriate community resourcesPlan and identify appropriate community resources

22. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22 Alzheimer's Disease Implementation Maintain optimal nutritionMaintain optimal nutrition Counseling and communication techniquesCounseling and communication techniques Health teaching and health promotionHealth teaching and health promotion Referral to community supportsReferral to community supports Structure the environment to support cognitive functionsStructure the environment to support cognitive functions Pharmacological interventionsPharmacological interventions

23. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23 Pharmacological Interventions for Alzheimer’s Disease Tacrine (Cognex)Tacrine (Cognex) Donepezil (Aricept)Donepezil (Aricept) Rivastigmine (Exelon)Rivastigmine (Exelon) Galantamine (Razadyne)Galantamine (Razadyne) Memantine (Namenda)Memantine (Namenda) Slows the rate of cognitive decline Potent acetylcholinesterase inhibitors

24. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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 24

25. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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) 25

26. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 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 26

27. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Caregiver Difficulties  Wandering behaviors  Sundowning disorientation  Activities of Daily Living  Medication management  Burnout and fatigue 27

28. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Caregiver Resources  Family meetings  Alzheimer’s Disease and Related Disorders Association (ADRDA)  Caregiver support groups  Identify community resources  ID bracelet for the client 28