Download COGNITIVE DISORDERS PP

Chapter 15
Cognitive Disorders
Copyright © 2009 by Saunders, an imprint of Elsevier Inc.
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Concept of Cognitive Disorders
• Cognition: process that is intellectual and
perceptual and closely integrated with an
individual’s emotional and spiritual values
• Cognitive disorders classified in DSM-IVTR
– Delirium
– Dementia
– Amnestic disorder
– Cognitive disorder not otherwise specified
(NOS)
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Cognitive Disorders:
Prevalence and Comorbidity
• Prevalence: delirium
– Present in 60% of nursing home residents
age 75 or older
– 80% of people with a terminal illness develop
delirium near death
• Comorbidity: delirium
– Delirium always exists secondary to another
medical condition or substance use
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Cognitive Disorders:
Prevalence and Comorbidity
• Comorbidity: amnestic disorders
– Amnestic disorders are always secondary to
underlying causes
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Cognitive Disorders:
Prevalence and Comorbidity
• Prevalence: dementia
– Alzheimer’s disease (most common dementia)
is 4th leading cause of death in U.S.
– Lifetime prevalence of Alzheimer's disease is
up to 5% by age 65 and up to 50% by age 85
• Comorbidity: dementia
– 80% of dementia is irreversible and primary
– Reversible dementias can be secondary to
other pathological processes (neoplasms,
trauma, infections, and toxins)
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Biological Theory Related to
Alzheimer’s Disease (AD)
• Age is most important risk factor
• Genetics
– Early-onset AD is rare; seems to be inherited
– Late-onset AD does not seem to have any
obvious inheritance pattern
• Risk factor identified is a form of a gene on
chromosome 19 that is responsible for making a
protein called apolipoprotein E (apoE)
• ApoE carries cholesterol in the blood and may be
involved in neuronal repair
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Alzheimer’s Disease:
Cultural Considerations
• AD is not affected by ethnicity
• Attitudes and perceptions of the
problematic behaviors in AD do vary
among cultural groups
– Caregiver emotions related to difficult
behaviors in AD seem to be related to the
value the particular culture places on the
ability to maintain control
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Delirium
• Occurs more often in older adults
• Causes: surgery, drugs, urinary tract
infections, pneumonia, cerebrovascular
disease, and congestive heart failure
• Essential feature: disturbed consciousness
coupled with cognitive difficulties
– Thinking, memory, attention, and perception
– Sundown syndrome (increased confusion in
evening hours) common
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Common Symptoms of Delirium
• Abrupt disruption in perception of
environment
• Disturbance in consciousness (awareness
of time, place, and person)
• Cognitive and perceptual disturbances
– Illusions (false perception of real stimuli)
– Hallucinations (primarily visual and tactile)
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Common Symptoms of Delirium
• Autonomic hyperactivity (increased vital
signs)
• Hypervigilance (constantly alert and
scanning room)
• Labile mood swings
• Agitation and anger
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Nursing Process: Assessment
Guidelines for Delirium
• Determine fluctuating levels of
consciousness
• Interview family to determine patient’s
normal level of consciousness and
cognition
• Review medical findings/diagnostic data to
help determine underlying conditions
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Nursing Process: Assessment
Guidelines for Delirium
• Assess vital signs, level of consciousness,
and neurological signs
• Determine patient’s risk for injury
• Assess need for comfort measures,
availability of immediate medical
intervention to prevent brain damage
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Nursing Process: Diagnosis and
Outcomes Identification for Delirium
• Common nursing diagnoses: Risk for
injury, Disturbed sleep pattern, Acute
confusion, Self-care deficits (specify),
Disturbed sensory perception
• Outcomes identification
– Primary outcome: patient will return to
premorbid level of functioning
– Other outcomes related to maintaining safety,
becoming reoriented, and refraining from
pulling out IV, nasogastric, or other tubes
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Nursing Process: Planning and
Implementing for Delirium
• Medical management directed toward
identification and treatment of cause of
delirium
• Nursing implementations directed toward
maintaining patient safety; communicating
in simple, concrete phrases; using reality
orientation aids (clocks, calendars);
maintaining same staff if possible; and
encouraging family to be supportive
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Communication Guidelines for the
Patient with Delirium
• Keep distractions to minimum when
communicating with patient
• Always identify self
• Speak slowly, with short, simple
words/phrases
• Focus on one piece of information at a
time
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Communication Guidelines for the
Patient with Delirium
• Talk with patient about familiar and
meaningful things in life
• Reinforce reality when patient is delusional
or having illusions
• Have patient wear any eyeglasses/hearing
aids
• Use reality orientation tools: clocks,
calendars, well-lit room, family pictures
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Nursing Process:
Evaluation for Delirium
• Long-term outcomes include:
– Patient will remain safe
– Patient will be oriented to time, place, and
person
– Underlying cause will be identified and treated
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Nursing Process:
Evaluation for Delirium
• Short-term goals related to ongoing
changing condition of patient
– Are vital signs stable?
– Have patient’s skin turgor and urine specific
gravity remained normal?
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Dementia
• Progressive deterioration in intellectual
functioning, memory, ability to problem
solve/learn new skills, decline in ability to
perform activities of daily living and
impaired judgment
• Various types of dementia identified,
Alzheimer’s most common
– All dementias present with common
symptoms
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Common Symptoms of Dementia
• Defensive behaviors in early dementia
– Denial: attempt to hide memory deficits
– Confabulation: making up of stories to
preserve self-esteem when person doesn’t
remember
– Perseveration: repetition of phrases (often
occurs under stress)
– Avoidance of questions
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Pathophysiology of
Alzheimer’s Disease
• Brain damage begins long before
symptoms appear
• Specific changes identified leading to end
result of brain atrophy
– Buildup of beta amyloid protein, resulting in
neuritic plaques (degenerated neurons)
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Pathophysiology of
Alzheimer’s Disease
– Neurofibrillary tangles (damaged remains of
microtubules allowing nutrients to flow
through neurons) forming in hippocampus
– Granulovascular degeneration (filling of brain
cells with fluid and granular material)
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Cardinal Symptoms in Dementia
• Amnesia: memory loss
– Short-term memory first loss
– Long-term memory loss occurs later in
disease
• Aphasia: loss of language ability
• Apraxia: loss of purposeful movement in
absence of sensory/motor impairment
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Cardinal Symptoms in Dementia
• Agnosia: loss of sensory ability to
recognize objects
• Disturbances in executive functioning
– Planning, organizing, abstract thinking
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Stages of Alzheimer’s Disease
• Stage 1: mild
– Characterized by short-term memory loss
• Stage 2: moderate
– Progressive memory loss, declines in
instrumental activities of daily living, social
withdrawal
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Stages of Alzheimer’s Disease
• Stage 3: moderate to severe
– Loss of ADL (dressing/grooming), difficulty
communicating, institutional care usually
needed
• Stage 4: end stage
– Family recognition disappears; forgets how to
eat, swallow, chew; mobility problems,
institutional care needed
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Diagnosis of Alzheimer’s Disease
• Important to rule out other causation
– Depression, neurological, medical problems,
effect of medications, nutritional deficits, fluid
and electrolyte imbalances
• No definitive test for AD
– Studies such as PET, SPECT, and MRI can
diagnose cerebral atrophy
– Mental status questionnaires (Mini-Mental
Status Exam) increase early detection
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Nursing Process: General Assessment
Guidelines for Dementia
• Identify any general medical conditions
that may be contributing to symptoms
• Determine potential for self- or other harm
• Explore family knowledge of disease
process as well as coping skills and use of
available community resources
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Nursing Process: General Assessment
Guidelines for Dementia
• Review all medications patient currently
taking
• Determine patient’s current level of
cognitive functioning
• Determine safety measures necessary in
home environment, especially wandering
precautions
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Nursing Process: Diagnosis and
Outcomes Identification for Dementia
• Common nursing diagnoses
– Risk for injury, Impaired verbal
communication, Impaired environmental
interpretation syndrome, Impaired memory,
Chronic confusion, Compromised or disabled
family coping
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Nursing Process: Diagnosis and
Outcomes Identification for Dementia
• Outcome identification
– Outcomes directed toward symptoms
manifested, with safety outcomes always
priority
• Communication needs, caregiver role strain,
impaired environmental interpretation, self-care
needs
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Nursing Process: Planning and
Implementing for Dementia
• Care geared toward patient’s and
caregiver’s immediate needs
– Transportation services, supervision/care
when primary caregiver not at home, referrals
to day care centers, information on support
groups
• Complex, changing needs of patient can
take place in variety of settings
– Hospital, home, long-term care facilities,
community
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Communication Guidelines for the
Patient with Dementia
• Always identify self and call patient by
name
• Speak slowly, using short words/phrases
• Focus on one piece of information at a
time
• Talk with patient about familiar and
meaningful things
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Communication Guidelines for the
Patient with Dementia
• When patient becomes delusional,
reinforce reality if it does not cause undue
anxiety
• Intervene in arguments between patients
and remove from each other’s presence
• Use reality orientation aids: clocks,
calendars, family pictures, signs
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Treatment for Dementia:
Milieu Therapy in Home
• Safe environment
– Restrict use of car, remove throw rugs,
minimize sensory stimulation; if patient
becomes upset—listen and then change
subject, label all rooms and drawers, install
safety bars in bathroom
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Treatment for Dementia:
Milieu Therapy in Home
• Wandering
– Put mattress on floor, have patient wear
MedicAlert bracelet, alert local
police/neighbors, put complex locks on doors
• Useful activities
– Provide picture books; simple activities using
large muscle groups; encourage group
activities familiar to patient
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Treatment for Dementia: Medications
• Cholinesterase inhibitors: increase
available acetylcholine (thought to
enhance memory)
– Examples: galantamine (Reminyl),
rivastigmine (Exelon), donepezil (Aricept)
• N-methyl-D-aspartate (NMDA): antagonist
at NMDA-glutamatergic ion channels,
making more acetylcholine available
– Example: memantine (Namenda)
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Treatment for Dementia:
Medications for Behavioral Symptoms
• Used with extreme caution
– Age affects metabolism, absorption, and
elimination of drugs
– Older adults more sensitive to medications
and side effects
– Principle: start low and go slow
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Treatment for Dementia:
Medications for Behavioral Symptoms
• Medications used
– SSRIs: for coexisting depression
– Atypical antipsychotics: for hallucinations,
delusions, agitation, combativeness
• Latest research is to use these medications
sparingly
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Nursing Process: Evaluation
• Outcomes need to be in measurable
terms, within capability of patient and
frequently evaluated
• Overall outcomes for treatment
– Promote patient’s optimal level of functioning
– Retard further regression when possible
– Use all existing supports and services
available
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