COGNITIVE DISORDERS
- The term cognition refers to the broad range of mental abilities that
enable us to know about the world around us. These abilities include
memory, language, attention, perception, and reasoning.
- Cognition is the ability of your brain to think, to process and store
information, to solve problems. Cognition is a high level of behaviour
unique to humans. This behaviour is disrupted by an illness.
- Gerontology is the scientific discipline that deals with aging, and
neurogerontology more specifically deals with the aging nervous system.
- Cognitive disorders are necessarily brain disorders, and these are
increasingly common after middle age. Perhaps the most important of
these illnesses is Alzheimer's disease, one cause of severe cognitive loss
(dementia) in old age.
- Physicians and scientists in the Division of Cognitive Disorders and
Neurogerontology are particularly interested in memory loss and
dementia.
Delirium
- Delirium is a sudden, fluctuating, and usually reversible cognitive disorder
characterized by disorientation, the inability to pay attention, the inability
to think clearly, and a change in the level of consciousness.
- Delirium is an abnormal mental state, not a disease. Although the term
has a specific medical definition, it is often used to describe any type of
confusion.
- Because delirium is a temporary condition, determining how many people
have it is difficult. Delirium, which is usually a sign of a newly developed
disorder, affects about one third of hospitalized people aged 70 or older.
Cause:
- Development or worsening of almost any disorder
- Extreme illness
- Drugs that affect brain function.
- Less severe conditions in older people
- Disorders that cause nerve degeneration. (stroke, dementia)
- Relatively minor illness, such as retention of urine or feces
- Sensory deprivation, such as that due to being socially isolated or not
wearing glasses or hearing aids; or prolonged sleep deprivation.
- The sensory and sleep deprivation that occurs in intensive care units
(ICUs) may contribute to delirium. This disorder is sometimes called ICU
psychosis.
- Delirium is also very common after surgery
- Most common reversible cause of delirium is drugs.
- In younger people, ingestion of poisons (such as rubbing alcohol or
antifreeze), use of illicit drugs, or acute intoxication with alcohol
- Abnormal blood levels of electrolytes, such as calcium, sodium, or
magnesium, can interfere with the metabolic activity of nerve
- Abnormal electrolyte levels may result from use of a diuretic, dehydration,
or disorders such as kidney failure and widespread cancer.
- An underactive thyroid gland (hypothyroidism) causes delirium with
lethargy; an overactive thyroid gland (hyperthyroidism) causes delirium
with hyperactivity.
- In younger people, the cause of delirium is usually a condition that directly
affects the brain—for example a brain infection, such as meningitis or
encephalitis.
Symptoms:
- The hallmark is the inability to pay attention.
- Lacks concentration.
- Sudden confusion about time and, at least partially, about place. Thinking - Aspirin
is confused, and people with delirium ramble, sometimes becoming
incoherent. - Barbiturates

- If delirium is severe, people may not know who they are. Thinking is - Benzodiazepines
confused, and people with delirium ramble, sometimes becoming
incoherent. - Hypoglycemic agents

- The level of consciousness may fluctuate between increased wakefulness - Insulin

and drowsiness.
- Cardiac glycosides
- Sundowning phenomenon. Symptoms often change within minutes and
- Narcotics
tend to worsen late in the day

- Often sleep restlessly or reverse their sleep-wake cycle - Propranolol

- Reserpine
- Frightened by bizarre visual hallucinations

- Paranoia or have delusions - Thiazide diuretics

Medical Management:
- Personality and mood may change.

- If the cause of delirium is not quickly identified and treated, the person - Hypoactive delirium - No specific pharmacologic treatment
may become increasingly drowsy and unresponsive, requiring vigorous - Sedatives to prevent inadvertent self-injury but sedatives and
stimulation to be aroused (a condition called stupor).
benzodiazepines are avoided – this may worsen delirium
- Stupor may lead to coma or death. - Exemption to this is delirium induced by alcohol withdrawal.
- Delirium is often the first sign of another, sometimes serious disorder,
- Haloperidol 0.5-1 mg to decrease agitation
especially in older people.
- Supportive medical measures
Drugs Causing Delirium:
Assessment:
- Anticonvulsants
- History of use of psychotropic Drugs
- Anticholinergics
- History of substance or alcohol abuse
- Antidepressants
- Disturbed psychomotor behavior
- Antihistamines
- Often have rapid and unpredictable mood shifts
- Antipsychotics
 - Thought processes are often disorganized and make no sense. - Many different conditions can result in dementia in later life. The
most common is Alzheimer's Disease, accounting for about 50% of all
- Altered level of consciousness cases. The next most common is vascular dementia.
- Judgment is impaired - Alzheimer's Disease involves a gradual change in the neurons, or nerve
cells in the brain. There are tangles inside the nerve cell and degenerating
- Disturbed sleep-wake cycles.
nerve endings. Other deficiencies also occur in the neurotransmitters, the
Nursing Interventions: chemical messengers that allow brain cells to send signals to each other.
- Ensure client’s safety
- administer medications judiciously as ordered
- Vascular dementia involves repeated damage to areas of the brain
- Teach client to request assistance for activities caused by blockages in the blood vessels (small strokes). Vascular
- Close supervision must be rendered dementia is what used to be referred to as hardening of the arteries.
- Managing client’s confusion
Classifications of Dementia:
- Speak in a calm manner in a clear low voice
- Allow adequate time for client to comprehend and respond Dementia is classified as cortical or subcortical depending on the area of
- Allow client to make decisions brain affected.
- Provide orienting verbal cues
- Use supportive touch if appropriate - Cortical dementia causes problems in memory, thinking, and language.
- Controlling environment to reduce sensory overload Alzheimer's Disease is a disorder that causes cortical dementia. The
- Provide a quiet environment cognitive problems, depending on their nature, are called aphasia,
- Monitor client’s response to visitors apraxia, amnesia, and agnosia. These problems may include difficulty
- Validate client’s anxiety and fears, but do not reinforce finding words, difficulty comprehending written or spoken material, and
misperceptions even mutism. Speech, which is the machinery for sound, is usually normal;
- Promoting sleep and proper nutrition however, it is the language component that breaks down. The memory
- Monitor sleep and elimination patterns problem is often an inability to learn new information.
- Monitor food and fluid intake
- Discourage daytime napping Insight into the condition is usually absent and a person's mood is
- Encourage exercise during day unconcerned or uninhibited. The motor system is normal, at least in the
Dementia early stages.

- Dementia is a label for a cluster of symptoms involving deterioration in

behaviours such as memory, language, and reasoning. The deterioration
results from a disease process in the brain. The disease progresses from
mild through severe stages and interferes with the ability to function
independently in everyday life. Dementias are fatal medical diseases that
have major psychosocial consequences.
Conditions Result in Dementia:
- Subcortical dementia affects parts of the brain below the cortex and is
characterized by slowing, difficulty in retrieving information from memory,
and altered mood. Parkinson's disease and multiple sclerosis are examples
of a condition that can result in a subcortical dementia. Language ability is
usually normal, although speech is dysfunctional and the motor system
may result in stooped or extended posture, increased muscle tone, and
tremors. Memory problems are due to a difficulty in retrieving information
 that is in fact learned. The person's mood may be either apathetic or
depressed, and insight into the condition is usually present.
Types of Dementia:
- Alzheimer’s Type Demetia
is an irreversible, progressive disorder in which brain cells (neurons)
deteriorate, resulting in the loss of cognitive functions, primarily memory,
judgment and reasoning, movement coordination, and pattern recognition.
In advanced stages of the disease, all memory and mental functioning
may be lost
- Vascular Dementia
is a degenerative cerebrovascular disease that leads to a progressive
decline in memory and cognitive functioning. It occurs when the blood
supply carrying oxygen and nutrients to the brain is interrupted by a
blocked or diseased vascular system
- Pick’s Disease
Pick's Disease is the result of a build-up of protein in the affected areas of
the brain. The accumulation of abnormal brain cells, known as Pick's
bodies, eventually leads to changes in character, socially inappropriate
behavior, and poor decision making, progressing to a severe impairment in
intellect, memory and speech. Pick's Disease is a rare disorder that causes
the frontal and temporal lobes of the brain, which control speech and
personality, to slowly atrophy.
- Creutzfeldt-Jacob Disease
is known as a prion disease, which means that healthy brain tissue
deteriorates into an abnormal protein that the body cannot break down.
CJD is a type of transmissible spongiform encephalopathy (TSE).
"Spongiform" refers to the characteristic appearance of an infected brain,
which becomes filled with holes until it looks like a sponge under a
microscope
- Huntington’s Disease
Huntington's Disease affects someone's ability to think, talk and move by
destroying cells in the basal ganglia, the part of the brain that controls
these capacities. Caused by a gene mutation that leads to a toxic
accumulation of protein in the brain, Huntington's is inherited from either
one or both parents. The general symptoms in early stages can include
poor memory; difficulty making decisions; mood changes such as
increased depression, anger or irritability; a growing lack of coordination,
twitching or other uncontrolled movements; difficulty walking, speaking,
and/or swallowing.
- HIV Dementia
AIDS dementia complex (ADC)—dementia caused by HIV infection—is a
complicated syndrome made up of different nervous system and mental
symptoms. It is characterized by cognitive deficits such as inattentiveness,
impaired concentration and problem solving, forgetfulness, and impaired
reading, motor abnormalities such as tremors, slurred speech, ataxia, and
generalized hyperreflexia; and behavioral changes such as sluggishness
and social withdrawal.
- Parkinson’s Disease
- Dementia caused by head trauma
4 As in Dementia:
- Amnesia - memory impairment
- Aphasia - language disturbance
- Apraxia - unable to perform motor activities
- Agnosia - difficulty in identifying objects
Conditions that Results to Dementia:
- Alzheimer's disease
- Limbic encephalitis
- Vascular dementia
- Heavy metal exposure
- Lewy body disease - – Cerebral Blood Flow – patient inhales radioactive gas and blood flow is
monitored
- Normal pressure hydrocephalus
- – Magnetic Resonance Imaging (MRI) – patient placed in magnetic field
- Parkinson's disease and radio waves used to produce picture of brain.
- Post-traumatic dementia - • Mental Status Exam
- Pick's disease
- • Physical Status Exam
- Multiple sclerosis
- • Laboratory tests targeted at identifying general medical and
- Jakob-Creutzfeldt disease substance-related causes

- Idiopathic basal ganglia calcification Assessment:

- Neurosyphilis - Level of consciousness – not affected

- Acquired immune deficiency syndrome (AIDS) - Thought processes is impaired

- Fungal infections - Mental function is lost, relatively consistently for all functions

- Tuberculosis - Memory is lost, especially for recent events

- Progressive supranuclear palsy - Use of language - sometimes has difficulty finding the right word

- Huntington's disease - Mood is usually depressed and anxious in early stage, labile mood, restless
pacing, angry out-bursts in later stage.
Diagnostic Exams:
- Self-concept is usually angry or frustrated
- Psychological Tests
- Often experiences disturbed sleep-wake cycles.
- • Neurological Tests
- Has at least one of the 4 A’s
- – Electroencephalograph (EEG) – measures electrical activity of brain
cells Nursing Interventions:

- Promote client’s safety

- – Computerized Axial Tomography (CAT) – assessed brain damage by X-
ray - Offer unobtrussive assistance with or supervision of activities
- – Positron Emission Tomography (PET) – glucose metabolism in brain is - Identify environmental triggers to help client avoid them
monitored
- Promote adequate sleep and proper nutrition, hygiene and Feature Delirium Dementia
activity

- Sit with client while eating Development Sudden Slow

- Monitor bowel elimination pattern Duration Days to weeks Months to years

- Remind client to urinate Presence of other Almost always present; Possibly none
disorders or physical may be a severe illness,
- Encourage mild physical activities
problems drug use or withdrawal,
- Structure the environment and routine or a problem with
metabolism
- Encourage client to follow regular routines and habits

- Monitor environmental stumulation, and adjust when needed Variation at night Almost always worse Often worse

- Provide emotional support Attention Greatly impaired Maintained until late stages

- Be kind, respectful, calm, and reassuring, pay attention to client Level of Fluctuates from Normal until late stages
consciousness lethargy to agitation
- Use supportive touch when necessary

- Promote interaction and involvement (Milieu management) Orientation to Varies Impaired

surroundings
- Plan activities according to client’s interest and abilities
Use of language Slow, often incoherent, Sometimes difficulty finding the
- Allow the client to have familiar objects around him/her -> reality and inappropriate right word
orientation, self-worth, dignity

- Reminisce with client about the past Memory Jumbled and confused Lost, especially for recent events

- Be alert to nonverbal cues Mental function Lost, variably and Lost, relatively consistently
unpredictably for all functions
- Employ techniques of distraction

- Provide a list of community resources, support groups Cause Usually an acute illness Usually Alzheimer's disease,
or drugs; in older vascular dementia, or Lewy
people, usually body dementia
Comparing Delirium and Dementia infection, dehydration,
or drugs
 Need for treatment Emergency medical Nonemergency medical Memory in Amnestic Disorder:
attention attention
- Impairment in ability to learn new information (Anterograde amnesia)

- Impairment in ability to recall previously learned information (Retrograde

Parkinson’s Disease amnesia)
- Parkinson's disease (PD) is commonly viewed as an extrapyramidal motor
disorder. Hence, a substantial body of research has focused on
understanding the neural mechanisms underlying the most apparent
symptoms (tremors, slowness, initiation of movements) and on treatment
of these debilitating clinical manifestations. However, PD is more than a
motor disease; it also affects thinking, reasoning, learning, processing
speed, and other cognitive abilities. Consequently, Parkinson's patients
exhibiting motor and cognitive symptoms present unique challenges for
the assessment and treatment of psychopathology in their disease
process. In such patients, both quality of life and treatment outcome are
severely compromised. The cognitive changes seen in PD patients are less
understood and studied than parkinsonian motor symptoms.

Non-Motor Symptoms of Parkinson’s Disease:

- Neuropsychiatric and cognitive:
- Depression
- Anxiety
- Psychosis
- Dementia
- Apathy
- Fatigue
- Sleep disturbance

Amnestic Disorder

- Amnestic disorders present as deficits in memory, either in the inability to

recall previously learned information or the inability to retain new
information. The cognitive defect must be limited to memory alone; if
additional cognitive defects are present, a diagnosis of dementia or
delirium should be considered. In addition to defect in memory, there must
be an identifiable cause for the amnestic disorder

- Amnestic disorders are reversible in some cases.