Cognitive Disorders

Cognition involves the brain’s ability to process, retain,

and use information.

Cognitive abilities include reasoning, judgment,

perception, attention, comprehension, and memory.

Disruption of these functions impairs the person’s ability to

make decisions, solve problems, interpret the environment,
and learn new information.
 Cognitive Disorders
Delirium Dementia Amnestic
General medical Alzheimer's type General medical
Substance-related Vascular origin Substance-related
Multifactorial HIV-related
substance induced Head trauma-related
not known Parkinson's-related
Huntington's-related
Pick's-related
Creutzfeldt -Jakob-
related
General medical origin
Substance-related
Multifactorial
 Delirium
Delirium:
disturbance of consciousness
a change in cognition
Perceptual disturbance
• Acute and fluctuating
• Difficulty paying attention, distractibility,
and disorientation
• Memory - often impaired
• Sensory disturbances include illusions,
misinterpretations, hallucinations
• Disturbances in sleep/wake cycle, anxiety,
fear, irritability, euphoria, apathy
 Delirium (cont’d)
• Risk factors: hospitalization for general
medical conditions, older acutely ill
clients, severe physical illness, older age,
and baseline cognitive impairment
• Etiology: identifiable physiologic,
metabolic, or cerebral disturbance or
disease or from drug intoxication or
withdrawal
 Treatment and Prognosis
• Treatment of the underlying medical
condition
• 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
 Psychopharmacology and Other
Medical Treatment
• If quiet and resting, no medication
• psychomotor agitation- sedation with an antipsychotic/ anti
anxiety may prevent inadvertent self-injury
• alcohol withdrawal - benzodiazepines
• Adequate food and fluid (calories,CHON, vits, thiamine)
• Physical restraints only when necessary
• Orient to person, place and time
 Application of the Nursing
Process: Delirium (cont’d)
Data Analysis
Nursing diagnoses may include:
• Risk for Injury
• Acute Confusion
• Disturbed Sensory Perception
• Disturbed Thought Processes
• Disturbed Sleep Pattern
• Risk for Deficient Fluid Volume
• Risk for Imbalanced Nutrition: Less Than Body
Requirements
 Application of the Nursing
Process: Delirium (cont’d)
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)
 Application of the Nursing
Process: Delirium (cont’d)
Intervention
• Promoting safety
• Managing confusion
• Promoting sleep and nutrition
 Dementia
• Dementia involves multiple cognitive
deficits, primarily memory impairment
– J - Judgement
– A - affect
– M - memory
– C - confusion
– O -orientation
• and at least one of the following:
– Aphasia
– Apraxia
– Agnosia
– Disturbance in executive functioning
• Dementia is progressive
 Classification
1. Primary – not reversible, progressive
1. Alzheimer’s, Multi infarct, Pick’s
Disease
2. Secondary – as a result of
pathological process.
 Onset and Clinical Course
• Mild (excessive forgetfulness, difficulty finding
words, loses objects, anxiety about loss of
cognitive abilities)
• Moderate (confusion, progressive memory loss,
can’t 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
• Alzheimer’s disease
• Vascular dementia (may have sudden onset;
progression may be arrested with treatment)
• Pick’s disease
• Creutzfeldt-Jacob disease
• Dementia due to HIV
• Parkinson’s disease
• Huntington’s disease
• Dementia due to head trauma
 Treatment and Prognosis

• Identify and treat underlying cause

whenever possible
• No therapies have been found to
reverse or retard degenerative
dementias
• Progressive deterioration of physical and
mental abilities until death
 Treatment and Prognosis (cont’d)

• Acetylcholine precursors, cholinergic

agonists, and cholinesterase inhibitors such
as tacrine (Cognex), donepezil (Aricept),
rivastigmine (Exelon), and galantamine
(Reminyl) temporarily slow the progress of
dementia
• Symptomatic treatment of behaviors such as
delusions, hallucinations, outbursts, and
labile moods.
 Application of the Nursing Process:
Dementia
Assessment
• History: may be unable to provide an accurate and
thorough history; interview family, friends, or
caregivers
• 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
 Application of the Nursing
Process: Dementia
Assessment:
• 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
Application of the Nursing Process:
Dementia (cont’d)
Assessment (cont’d)
• Thought processes and content: initially loses
ability to think abstractly; 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; inability to
concentrate; chronic confusion, disorientation
(eventually even to person); visual
hallucinations common
 Application of the Nursing Process:
Dementia (cont’d)
Assessment (cont’d)
• Judgment and insight: initially
recognizes he or she is losing
abilities, and then insight fades
altogether; judgment impaired due
to cognitive deficits; worsens over time; at risk
for wandering, getting lost
injuring self,
• unable to perceive harm
 Application of the Nursing
Process: Dementia (cont’d)
Assessment (cont’d)
• Self-concept: initially client is frustrated at
losing things or forgetting, sad about “getting
old”; sense of self deteriorates until client
doesn’t 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
 Application of the Nursing
Process: Dementia (cont’d)
Assessment (cont’d)
• Physiologic and self-care considerations:
disturbances in sleep/wake cycle, ignoring body
cues to eat, drink, urinate, etc.; lose abilities to
do personal hygiene, even feeding self
Application of the Nursing Process:
Dementia (cont’d)
Data Analysis
Nursing diagnoses include:
• Risk for Injury • Impaired Environmental
• Disturbed Sleep Pattern Interpretation Syndrome
• Risk for Deficient Fluid • Impaired Memory
Volume • Impaired Socialization
• Risk for Imbalanced • Impaired Verbal
Nutrition Communication
• Chronic Confusion • Ineffective Role
Performance
 Application of the Nursing
Process:
Outcomes
Dementia (cont’d)
The client will:
• Be free of injury
• Maintain an adequate balance of activity and rest,
nutrition, and 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
 Application of the Nursing
Process: Dementia (cont’d)
Intervention
• Promoting safety
• Promoting adequate sleep, nutrition,
hygiene, and activity
• Structuring the environment and
routine
 Application of the Nursing
Process: Dementia
Intervention (cont’d)
(cont’d)
• Providing emotional support
– Supportive touch
• Promoting interaction and involvement
– Reminiscence therapy
– Distraction
– Time away
– Going along
 Mental Health Promotion

• Research continues to identify risk

factors for dementia (elevated levels of
plasma homocysteine)
• Regular participation in brain-
stimulating activities
 Related Disorders
Amnestic Disorder
• Disturbance in memory resulting from the
physiologic effects of a general medical condition
(stroke,head injury, carbon monoxide
poisoning, chronic alcohol ingestion)
• Confusion, disorientation, and attentional deficits
are common
• Clients do NOT have the multiple cognitive deficits
seen in dementia such as aphasia, apraxia, agnosia,
and impaired executive functions
 Related Disorders (cont’d)
Korsakoff’s Syndrome
• Alcohol-induced amnestic disorder resulting from a
chronic thiamine or vitamin B deficiency
• Confusion, disorientation, and attentional deficits
are common
• Clients do NOT have the multiple cognitive deficits
seen in dementia such as aphasia, apraxia, agnosia,
and impaired executive functions
 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
 Geriatic Considerations
1. Do not push too fast in getting information, assist in ADL,
insisting to socialize.
2. 3 R’s – routine, reinforment, repetition, (relaxation).
3. Avoid dependency
4. Do not isolate
5. Protect from injury
6. communicate – simple, clear and concise. Face to face,
use visual cues
7. Orient frequently
8. 3 P’s – protecting dignity, preserving functioning,
promoting quality of life.