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Cognitive Disorders
Factors causing injuries to brain: electrolyte imbalances;
ischemia; ↓’d O2 supply
Classifications: delirium; dementia; amnestic disorder
Amnestic Disorder- loss in both short & long term memory;
always 2o other causes (generally head trauma)
Delirium- acute change in LOC & cognition that develops
over a short period (levels fluctuate); potentially reversible;
attention shifts rapidly from one stimulus to another; speech is
difficult to understand due to rapid stimulus shifting
-causes- dehydration; drug toxicities; abuse of drugs; exposure
to toxins; polypharmacy; hypoxia; infection; certain drugs
(digitalis, antiHTN, antihistamines, benzos, antiparkinsons,
anticholinergics)
-characterized by alterations in: memory; abstract thinking;
judgment; perceptionprogressive decline in intellectual
fxn’ing & ↓’d capacity to perform ADL’s; disorientation to
time & place; mayhallucinations/ illusions; often causes 2 o
personality traits to manifest
aphasia-loss of ability to articulate or comprehend speech;
apraxia- inability to perform purposeful movements
-memory impairment; paranoia; catastrophic rx’sDisorganized behavior due to a severe shock or threatening
situation with which the person cannot cope; impulsiveness;
disinhibition- unrestrained behavior; spontaneous undressing
Stages:
1.mild- loss of drive, develop anergia, begin to have trouble w/
planning & memory loss
2.moderate- often dx’d here if not id’d in stage 1; trouble w/
date/address; hygiene starts to suffer; dress may be
inappropriate; mood lability; paranoia begins; still fxn’l but
may be dangerous
3.mod-severe- trouble w/ agnosia; require repeat instructions
(signs are helpful); wandering begins; generally require
institutionalization; agraphia (inability to express written
thought); hyperorality; hypermetamorphosis
4.late- u/a to communicate well, forget to feed self; total care
Pharm- ↑supply of acetylcholine
-Cognex (tacrine)
-Aricept (donezepil)
-Exelon (rivastigmine)
-sundowning- symptoms become more pronounced in evening
-interventions: correct fluid/elect imbalance; safety
precautions; ↓stimuli; reorientation (clocks, calendars); assess
(labs, LOC, physical needs, mood/behavior); ↑HOB slightly;
5-10min periods of interaction
*Folstein Mini Mental Exam
Dementia- Deterioration of intellectual faculties, such as
memory, concentration, and judgment; sometimes
accompanied by emotional disturbance and personality
changes
Classification: primary- irreversibly & progressive;
secondary- result of pathological process: metabolic, AIDS,
viral encephalitis, pernicious anemia, folic acid deficiency,
hypothyroidism, Korsakoff
Types of dementia:
Vascular- results from several sm strokes over period of
timegradual ↓ in fxn’ing
-risks: same as strokes
Korsakoffs syndrome- vit B1 or thiamine deficiency over time
(often seen in chronic drinkers)
Creutsfeldt-Jakob (mad cow)
Alzheimer’s- progressive deterioration in: intellectual fxn’ing,
memory, ability to solve problems & to learn new skills
-genetic link; ↓’d levels of acetyltransferase
-cerebral atrophy; neurofibiliary tangles in hippocampus;
senile plaques & granulovascular degeneration
-progression- 8 yrs from onset to end
Defenses:
-denial; confabulation-To fill in gaps in one's memory with
fabrications that one believes to be facts; preservation;
Somatoform Disorders- expression of psychological stress
through physical symptoms
-physical symptoms suggest medical disorder but no
demonstratable proof; symptoms linked to psychobiological
factors
Somatization disorder- *unconscious, multiple physical
complaints w/o apparent or provable cause; h/o pain in at least
4 diff sites, 2 or more GI symptoms other than pain, 1
sexual/reproductive, 1 neuro; comorbid w/ personality
disorders & depression (head, chest, back, joint, pelvis, N&V,
SOB, palpitations, dizziness, constipation); usually results in
social/work interference; ♀>♂
Hypochondriasis- fear of having a serious illness based on
misinterpretation of bodily symptoms or fxns; fears & worries
often based on single disease; tx is therapy fear lasts >6mos;
preoccupations persists despite tests; strong fear of
illness/death; concerns reoccur & may interfere w/ fxn’ing;
learned behavior; h/o trauma or abuse; comorbid w/
depression
Conversion disorder- u/a to explain range of neuro
symptoms affecting voluntary motor or sensory fxn (seizures,
impaired coordination/balance, paralysis, double vision,
blindness, deafness, difficulty swallowing, hallucinations); 2
key identifiers- no plausible explanation & symptoms occur as
result of psychological factors; comorbid w/ depression, DID,
personality disorders
-LaBelle indifference- lack of concern about symptoms
Factitious disorder- physical symptoms created for attention
or to achieve a purpose (workman’s comp, SSI, emotional
needs);
-Munchausen’s- induce physical symptoms; extensive
knowledge of health care, predictive relapse; symptoms persist
only when observed; seek med attention @ numerous
locations; reluctant to have family meet w/ HCP’s
-Munchausen by proxy- parents induce symptoms in children;
parent very friendly & cooperative & appear quite concerned
may have h/o Munchausen; suggestive signs- multiple
allergies; symptoms disappear when HCP present; parent
overly attached; general health conflicts w/ labs; siblings h/o
SIDS; children 15mo-6yrs @ greatest risk
through; difficulty organizing; avoids difficult tasks; loses
things; distracted; forgetful
-hyperactivity/impulsivity- fidgets & squirms; leaves seat;
runs & climbs excessively; acts as if driven by motor; talks
excessively; blurts out answers; difficulty waiting turn;
difficulty playing quietly; interrupts or intrudes
Body dysmorphic disorder- preoccupation w/ imagined
defect in appearance; serotonin deficiency; often seek
cosmetic surgery; common complaints skin, hair, face,
genitalia, hips, wt, body hair
Anxiety disorders- phobias, sleep disturbances, avoidant
disorders, overanxious disorder, PT SD
Tx for somatoform d/o- behavioral by exposure, reading,
taking & confronting personal fears; cognitive restructuring to
explore other possibilities for symptoms w/ positive self talk
& elimination of negative thoughts
Psychological responses to medical illness- responses are
triggered when illness is life altering; most common
responses- depression- (risk factor for noncompliance) ,
anxiety, substance use, denial, anger
-fear of dependency- exhibit inability to accept warmth,
nurturing, tenderness, refusal of tx; holistic assess is useful
indicator
-psychosocial assess- psychosoc, coping strategies, quality of
life overall ADL’s, social activities, social supports,
perception of quality of life, feelings & pain
-MI- guilt a precursor to major depression; family members
need chance to express feelings; giving family members sense
of control over care can ↓ stress levels
Problems of children & adolescents
Risk factors- poverty, parents mentally ill or substance abuse;
abuse; minority; teenage parents; families w/ parental conflict
or divorce; chronic illness or disability
Mental retardation- deficit in intellectual fxn; IQ<70; not
synonymous w/ mental illness
Learning disorders- impairment in specific academic area;
early ID
Pervasive developmental disorder- problem in global dev’t
-Rett’s disorder- problems after period (6mo) of normal
dev’t; ♀ only; psycho-motor retardation & expressivereceptive language
-Asperger’s disorder- qualitative impairment in social
interactions; no delays in cognition & language dev’t
-Autism- dev-global impairment: social, verbal/nonverbal;
onset <3yrs; lack of responsiveness to other; little evidence of
pleasure; insistence of routine; bizarre response to
environment; delayed/absent spoken language; restricted
pattern of behavior
Disruptive & attention deficit disorders
Oppositional defiant- negative/hostile lasting at least 6 mos;
not destructive to property; angry, defensive, easily annoyed
Conduct disorder (antisocial if >15yrs)- repetitive &
persistent violation of rights of others; often see cruelty to
animals, aggressiveness to younger children, impervious to
pain, fire setting, sexual acting out
ADHD- inattention & hyperactivity/impulsivity
-inattention (6/9): makes careless mistakes; difficulty
sustaining attention; does not seem to listen; does not follow
Depression-behavior may mask; may act out; depressive
themes in play, fantasy, art, verbalization
Bi-polarAdolescent depression- suicidal adol have earlier onset &
longer duration of depression; more turmoil in families; social
instability in year before attempt; often sexually abused during
adolescence
Psychosis- same dx criteria as adults; pos symptoms such as
delusion, hallucination, disorganized thinking
Maladaptive responses- inappropriate sexual activity;
homosexual problems; wt problems; occult involvement;
experiment w/ alcohol & other drugs