Cognitive Disorders

Cognition involves the brains ability to process, retain, and use information Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory Disruption of these functions impairs the persons ability to make decisions, solve problems, interpret the environment, and learn new information

DELIRIUM Delirium is a syndrome that involves disturbance of consciousness accompanied by a change in cognition It develops over a short period of time and fluctuates over time It causes difficulty in paying attention, distractibility, and disorientation. Sensory disturbances include illusions, misinterpretations, hallucinations, disturbances in the sleepwake cycle, anxiety, fear, irritability, euphoria, and apathy. Ten to fifteen percent of persons hospitalized for a general medical condition have delirium. It is more common in acutely ill geriatric clients and children with high fevers or taking certain medications. ETIOLOGY Delirium is caused by an underlying physiologic, metabolic, or cerebral disturbance, or by drug intoxication/withdrawal. TREATMENT AND PROGNOSIS Treatment of the underlying medical condition will usually resolve delirium. Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury. Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium. Alcohol withdrawal is managed medically with benzodiazepines. IV fluids or total parenteral nutrition may be needed. Occasionally, restraints are necessary so that tubes and catheters arent pulled out. Use judiciously and for short periods because restraints may increase agitation. APPLICATION OF THE NURSING PROCESS: DELIRIUM Assessment Assessment is ongoing and continuous because the clients level of consciousness and orientation may fluctuate. Thorough history of prescribed and over-the-counter medications needed General appearance and motor behavior: may be restless, picking at covers, agitated, getting out of bed, or sluggish and lethargic; speech is less coherent as delirium worsens.

Mood and affect: Client has rapid and unpredictable mood shifts with a wide range of emotions. Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition. Sensorium and intellectual processes: sensory misperceptions, disorientation, confusion, lack of attention and concentration Impaired judgment and insight: impaired judgment, varied insight Roles and relationships: usually no long-term effect unless previous problems existed Self-concept: how the person sees him- or herself Physiologic and self-care considerations: trouble sleeping, may ignore body cues such as hunger, thirst, or the urge to urinate or defecate

Data Analysis Primary nursing diagnoses include: Risk for Injury Acute Confusion Additional diagnoses based on individual client assessment: Disturbed Sleep Pattern Disturbed Thought Processes Disturbed Sensory Perceptions Risk for Imbalanced Nutrition Sensory-Perceptual Alterations Risk for Deficient Fluid Volume Outcomes The client will: Be free of injury Demonstrate increased orientation and reality contact Maintain an adequate balance of activity and rest Maintain adequate nutrition and fluid balance Return to optimal level of functioning (predelirium) Intervention Promoting safety Managing confusion Promoting sleep and nutrition Evaluation Client and family education necessary to prevent recurrence (see PowerPoint slide)

COMMUNITY-BASED CARE: DELIRIUM Referral may be necessary for community-based care or rehabilitation if client has lingering cognitive problems resulting from the medical condition. DEMENTIA Dementia involves multiple cognitive deficits, primarily memory impairment, and at least one of the following: aphasia, apraxia, agnosia, or disturbance in executive functioning. Dementia is progressive unless the underlying cause is treatable, such as vascular dementia, which is rare. CLINICAL COURSE Mild (excessive forgetfulness, difficulty finding words, loses objects, anxiety about loss of cognitive abilities) Moderate (confusion, progressive memory loss, cant do complex tasks, oriented to person and place, recognizes familiar people; by the end of this stage, requires assistance and supervision) Severe (personality and emotional changes, delusional, wanders at night, forgets names of spouse and children, requires assistance with activities of daily living) ETIOLOGY Various causes, but clinical picture similar for all: Alzheimers disease Vascular dementia (may have sudden onset; progression may be arrested with treatment) Picks disease Creutzfeldt-Jakob disease Dementia due to HIV Parkinsons disease Huntingtons disease Dementia due to head trauma CULTURAL CONSIDERATIONS Take into account whether client would be expected to know certain information, such as names of past presidents. Recognize differing beliefs about elders. TREATMENT AND PROGNOSIS Underlying cause, as in vascular dementia, is treated to prevent further deterioration. Medications such as tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) (stops progression for 2 to 4 months only) can be used to slow progression.

 Symptomatic treatment of behaviors such as delusions, hallucinations, outbursts, and labile moods, which vary among clients APPLICATION OF THE NURSING PROCESS: DEMENTIA Assessment May need to assess in small increments of time Obtain information from family and records, depending on clients cognitive abilities General appearance: aphasia, perseveration, slurring, eventual loss of language Motor behavior: apraxia, cannot imitate demonstrated tasks; finally, gait disturbance, making unassisted ambulation unsafe, then impossible May demonstrate uninhibited behavior: inappropriate jokes, sexual comments, undressing in public, profanity; familiarity with strangers Mood and affect: initially anxious and fearful over lost abilities, labile moods, emotional outbursts, catastrophic emotional responses; verbal or physical aggression possible; may become emotionally listless, apathetic, withdrawn Thought processes and content: initially loses ability to think abstractly, so cannot plan, sequence, monitor, initiate, or stop complex behavior; cannot solve problems; cannot generalize knowledge from one situation to another. Later, delusions of persecution are common. Sensorium and intellectual processes: initially memory deficits that worsen over time, confabulation to fill in memory gaps, agnosia, cannot write or draw simple objects; ability to concentrate or pay attention deteriorates until unable to do either; chronic confusion, disorientation (eventually even to person); visual hallucinations common Judgment and insight: initially recognizes he or she is losing abilities, then insight fades altogether; judgment impaired due to cognitive deficits; worsens over time; client at risk for wandering, getting lost, injuring self; unable to perceive harm Self-concept: initially client is frustrated at losing things or forgetting, sad about getting old; sense of self deteriorates until client doesnt recognize own reflection in mirror Roles and relationships: can no longer work, cannot fulfill roles at home, cannot attend social events, eventually confined to home. Family members often become caregivers but feel loved one has become a stranger. Physiologic and self-care considerations: disturbances in sleepwake cycle, ignoring body cues to eat, drink, urinate, etc.; loss of abilities to do personal hygiene, even feeding self Data Analysis Nursing diagnoses include: Risk for Injury Disturbed Sleep Pattern Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition

Chronic Confusion Impaired Environmental Interpretation Syndrome Impaired Memory Impaired Socialization Impaired Verbal Communication Ineffective Role Performance

Outcomes Outcomes for clients with dementia differ from other clients because of the progressive deterioration. The client will: Be free of injury Maintain an adequate balance of activity and rest, nutrition, hydration, and elimination Function as independently as possible, given his or her limitations Feel respected and supported Remain involved in his or her surroundings Interact with others Intervention Interventions are organized around a psychosocial model of dementia care and include: Promoting safety Promoting adequate sleep, hygiene, and activity, as well as proper nutrition Structuring the environment and routine Providing emotional support Promoting interaction and involvement (reminiscence, distraction, time away, going along) Evaluation Ongoing evaluation is necessary to revise plan of care as clients abilities diminish. COMMUNITY-BASED CARE: DEMENTIA Many persons with dementia are in the community for most of their lives: Family homes Adult day care centers Residential facilities Specialized Alzheimers units ROLE OF THE CAREGIVER Most caregivers are women (72%), either daughters (29%) or wives (23%). Caregivers need: Education about dementia and care needed by client

Help dealing with own feelings of loss Respite to care for own needs Support groups Assistance from agencies Role strain in caregivers is common because of too many conflicting demands and expectations (including expectations they have of themselves). Use of drugs and alcohol is common. Caregivers may feel unappreciated and may become socially isolated and unwilling to accept help from others. Without intervention, role strain may lead to neglect or abuse. RELATED DISORDERS Amnestic disorder Korsakoffs syndrome SELF-AWARENESS ISSUES Inability to teach a client with dementia Feelings of frustration or hopelessness Knowledge that there is progressive deterioration until death, with no hope for improvement