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Cognitive Disorders CHAPTER 17 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 1 Delirium Etiology 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3 Delirium – Clinical Picture • Disturbances in consciousness • Change in cognition • Develops over a short period of time • Common in hospitalized patients, especially older adults • Always secondary to another physiological condition • Is a transient disorder • If underlying condition corrected, complete recovery should occur Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Delirium Assessment • Four cardinal features – Acute onset and fluctuating course – Inattention – Disorganized thinking – Disturbance of consciousness Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5 Delirium Assessment • Cognitive and perceptual disturbances – Illusions – Hallucinations • Physical needs • Mood and physical behaviors • Attention span • Reasoning • Sleep and wake cycle Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Delirium Nursing Diagnoses • Risk for injury • Acute confusion • Deficient fluid volume • Insomnia, Sleep deprivation • Impaired verbal communication • Fear • Self-care deficit • Disturbed thought process Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 Delirium Outcomes Identification • Patient will return to premorbid level of functioning. • Patient will remain safe and free from injury while in the hospital. • Patient will be oriented to time, place, and person. • Patient will be free from falls and injury. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Delirium Implementation • Prevent physical harm due to confusion, aggression, or fluid and electrolyte imbalance. • Perform comprehensive nursing assessment to aid in identifying cause. • Assist with proper health management to eradicate underlying cause. • Use supportive measures to relieve distress. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10 Delirium Evaluation • Patient will remain safe. • Patient will be oriented to time, place, and person by discharge. • Underlying cause will be treated and ameliorated. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11 Dementia • Progressive deterioration of cognitive functioning and global impairment of intellect • No change in consciousness • Difficulty with memory, thinking, and comprehension • Majority of dementias are irreversible Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 Dementia Primary Versus Secondary • Primary – Irreversible – Progressive – Not secondary to any other disease – Example: Alzheimer's disease • Secondary – Result of some other pathological process – Example: AIDS-related dementia Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13 Alzheimer’s Disease Etiology • Biological factors – Cerebral atrophy – Neurofibrillary tangles – Neuritic plaques • Genetic Dementia of Alzheimer’s type Dementia from Huntington’s disease Dementia from Pick’s disease Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14 Alzheimer’s Disease Etiology • Environmental factor • Dementia from Creutzfeldt–Jakob disease Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15 Nursing Process • Assessment – Confabulation – Perseveration • Cardinal symptoms observed in AD – Amnesia or memory impairment – Aphasia – Apraxia – Agnosia – Disturbances in executive functioning Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 Nursing Process Poor judgment Decline in previous abilities Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17 Stages of Alzheimer's Disease • Stage 1 (Mild) – forgetfulness • Stage 2 (Moderate) – confusion • Stage 3 (Moderate to Severe) – unable to identify familiar objects or people • Stage 4 (Late) – end-stage Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18 Alzheimer’s Disease Nursing Diagnoses • Risk for injury • Impaired verbal communication • Impaired environmental interpretation syndrome • Impaired memory • Confusion • Caregiver role strain Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Alzheimer's Disease Outcomes Identification • Areas to target – Injury – Communication – Agitation level – Caregiver role strain – Impaired environmental interpretation: chronic confusion – Self-care needs Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20 Alzheimer's Disease Planning • Geared towards person’s immediate needs • Identify level of functioning • Assess caregivers’ needs • Plan and identify appropriate community resources Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21 Alzheimer's Disease Implementation • Maintain optimal nutrition • Counseling and communication techniques • Health teaching and health promotion • Referral to community supports • Structure the environment to support cognitive functions • Pharmacological interventions Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22 Pharmacological Interventions for Alzheimer’s Disease • Tacrine (Cognex) • Donepezil (Aricept) • Rivastigmine (Exelon) • Galantamine (Razadyne) • Memantine (Namenda) Slows the rate of cognitive decline Potent acetylcholinesterase inhibitors Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 23 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 24 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) Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 25 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 Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 26 Caregiver Difficulties Wandering behaviors Sundowning disorientation Activities of Daily Living Medication management Burnout and fatigue Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 27 Caregiver Resources Family meetings Alzheimer’s Disease and Related Disorders Association (ADRDA) Caregiver support groups Identify community resources ID bracelet for the client Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 28