Chapter 26

Delirium, Dementia, and Amnestic Disorders

Introduction
Disorders discussed in which a clinically significant deficit in cognition or memory exists.

Introduction (cont.)
The number of people with these disorders is growing because more people now survive into the high-risk period for dementia, which is middle age and beyond.

Delirium
Characterized by a disturbance of consciousness and a change in cognition that develop rapidly over a short period.

Delirium
Symptoms
Difficulty sustaining and shifting attention Extreme distractibility Disorganized thinking Speech that is rambling, irrelevant, pressured, and incoherent

Delirium (cont.)
Symptoms
Impaired reasoning ability and goaldirected behavior Disorientation to time and place Impairment of recent memory Misperceptions about the environment, including illusions and hallucinations

Delirium (cont.)
Symptoms
Psychomotor activity that fluctuates between agitation, purposeless movements, and a vegetative state Emotional instability

Delirium (cont.)
Symptoms include autonomic manifestations such as;
Tachycardia Sweating Flushed face Dilated pupils Elevated blood pressure

Delirium (cont.)
Usually begins abruptly. It can have a slower onset if the underlying etiology is systemic illness or metabolic imbalance. Duration is usually brief and subsides completely on recovery from the underlying determinant.

Predisposing Factors
Delirium due to a General Medical Condition Substance-Induced Delirium Substance-Intoxication Delirium Substance-Withdrawal Delirium Delirium due to Multiple Causes

Dementia
Defined as a syndrome of acquired persistent intellectual impairment with compromised function in multiple spheres of mental activity.

Dementia (cont.)
Symptoms
Impairment exists in abstract thinking, judgment, and impulse control. Conventional rules of social conduct are disregarded. Personal appearance and hygiene are neglected.

Dementia (cont.)
Symptoms
Language may or may not be affected. Personality change is common.

Dementia (cont.)
Reversible dementia is a function of the underlying pathological condition and of the availability and timely application of effective treatment.

Dementia (cont.)
As the disease progresses, signs include:

Apraxia Irritability and moodiness, with sudden outbursts over trivial issues Inability to care for personal needs independently Wandering away from the home area

Predisposing Factors
Dementia of the Alzheimers type

Onset is slow and insidious and the course of the disorder is generally progressive and deteriorating. Refinement of diagnostic criteria now enables clinicians to use specific clinical features to identify the disease at an accuracy rate approaching 85%.

Predisposing Factors (cont.)

Dementia of the Alzheimers type
Etiologies may include:

Acetylcholine alterations Accumulation of aluminum in body Alterations in the immune system Head trauma Genetic factors

Predisposing Factors (cont.)

Vascular Dementia
Dementia is due to significant cerebrovascular disease. There is a more abrupt onset than is seen in association with Alzheimers disease, and the course is more variable.

Predisposing Factors (cont.)

Vascular Dementia
Etiologies may include

Arterial hypertension Cerebral emboli Cerebral thrombosis

Predisposing Factors (cont.)

Dementia due to HIV Disease
Dementia results from brain infections caused by opportunistic organisms or the HIV-1 virus directly. Symptoms may range from barely perceptible changes to acute delirium to profound dementia.

Predisposing Factors (cont.)

Dementia due to Head Trauma
Posttrauma symptoms include

Headache Irritability Dizziness Diminished concentration and hypersensitivity to certain stimuli

Predisposing Factors (cont.)

Intellectual functioning and memory may also be impaired.

Predisposing Factors (cont.)

Dementia due to Parkinsons Disease
This is caused by a loss of nerve cells located in the substantia nigra and a decrease in dopamine activity. Cerebral changes in dementia due to Parkinsons disease sometimes resemble those of Alzheimers disease.

Predisposing Factors (cont.)

Dementia due to Huntingtons Disease
Damage from this disease occurs in the areas of the basal ganglia and the cerebral cortex. The client usually declines into a profound state of dementia and ataxia. Average course of the disease to complete incapacitation and death is about 15 years.

Predisposing Factors (cont.)

Dementia due to Creutzfeldt-Jakob disease
Onset of symptoms occurs between ages 40 and 60 years. Course is extremely rapid, with progressive deterioration and death within 1 year.

Predisposing Factors (cont.)

Dementia due to Creutzfeldt-Jakob Disease
Etiology is thought to be a transmissible agent known as a slow virus. There is a genetic component in 5 to 15 percent.

Predisposing Factors (cont.)

Dementia due to Other Medical Conditions
Endocrine disorders Pulmonary disease Hepatic or renal disease Fluid and electrolyte imbalance Frontal lobe or temporal lobe lesions

Predisposing Factors (cont.)

Substance-Induced Persisting Dementia

Related to the persistent effects of abuse of substances such as

Alcohol Inhalants Sedatives, hypnotics, and anxiolytics

Predisposing Factors (cont.)

Dementia due to Multiple Etiologies
Diagnosis used when the symptoms of dementia are attributed to more than one etiology.

Amnestic Disorders
Amnestic disorders are characterized by an inability to:
Learn new information despite normal attention Recall previously learned information

Amnestic Disorders (cont.)

Symptoms
Disorientation to place and time (rarely to self) Confabulation, the creation of imaginary events to fill in memory gaps

Amnestic Disorders (cont.)

Symptoms
Denial that a problem exists or acknowledgment that a problem exists, but with a lack of concern Apathy, lack of initiative, and emotional blandness

Amnestic Disorders (cont.)

Onset may be acute or insidious,

depending on underlying pathological process. Duration and course may be quite variable and are also correlated with extent and severity of the cause.

Predisposing Factors
Amnestic Disorder due to a General Medical Condition.
Head trauma Cerebrovascular disease Cerebral neoplastic disease Cerebral anoxia Herpes simplex virus-related encephalitis

Predisposing Factors (cont.)

Substance-Induced Persisting Amnestic Disorder Related to
Alcohol abuse Sedatives, hypnotics, and anxiolytics Toxins such as lead and mercury Medications such as anticonvulsants

Application of the Nursing Process/Assessment

The Client History: Areas of concern to be addressed

Type, frequency, and severity of mood
swings Personality and behavioral changes Catastrophic emotional reactions Cognitive changes Language difficulties

Assessment
History: Areas of concern to be addressed
Orientation to person, place, time, and situation Appropriateness of social behavior Current and past use of medications, drugs, and alcohol Possible exposure to toxins Client and family history of specific illnesses

Assessment (cont.)
Physical Assessment
Assessment for diseases of various organ systems that can induce confusion, loss of memory, and behavioral changes

Assessment (cont.)
Physical Assessment
Neurological examination to assess mental status, alertness, muscle strength, reflexes, sensory perception, language skills, and coordination

Assessment (cont.)
Physical Assessment
Psychological tests to differentiate between dementia and pseudodementia (depression)

Nursing Process
Diagnostic Laboratory Evaluations
Include blood and urine to test for

Various infections Hepatic and renal dysfunctions Diabetes or hypoglycemia Electrolyte imbalances Metabolic and endocrine disorders Nutritional deficiencies Presence of toxic substances

Nursing Process (cont.)

Other Diagnostic Evaluations May Include Electroencephalogram (EEG) Computed tomography (CT) scan Positron emission tomography (PET) Magnetic resonance imaging (MRI) Lumbar puncture to examine cerebrospinal fluid (CSF)

Diagnosis/Outcome Identification
Risk for trauma related to impairments in cognitive and psychomotor functioning Risk for self-directed violence related to depressed mood Risk for other-directed violence related to impairment of impulse control

Diagnosis/Outcome Identification (cont.)

Disturbed thought processes related to cerebral degeneration Low self-esteem related to loss of independent functioning Self-care deficit related to disorientation, confusion, memory deficits

Outcomes
The client:
Has not experienced physical injury Has not intentionally harmed self or others Has maintained reality orientation to the best of his or her capability Discusses positive aspects about self and life Fulfills activities of daily living with assistance

Nursing Process
PLANNING AND IMPLEMENTATION Provides a plan of care for the client with a cognitive disorder

Client/Family Education
Nature of the illness
Possible causes What to expect Symptoms

Client/Family Education (cont.)

Management of the Illness
Ways to ensure client safety How to maintain reality orientation Provide assistance with activities of daily living (ADLs) Nutritional information Difficult behaviors Medication administration Matters related to hygiene and toileting

Client/Family Education (cont.)

Support Services
Financial assistance Legal assistance Caregiver support groups Respite care Home health care

Nursing Process: Evaluation

Based on the accomplishment of outcome criteria

Medical Treatment Modalities

Delirium
Determination and correction of the underlying causes Staff to remain with client at all times to monitor behavior and provide reorientation and assurance

Medical Treatment Modalities (cont.)

Delirium
Room with low stimulus level Low-dose neuroleptic agents to relieve agitation and aggression

Medical Treatment Modalities (cont.)

Dementia
Primary consideration is given to etiology, with focus on identification and resolution of potentially reversible processes.

Medical Treatment Modalities (cont.) Dementia

For cognitive impairment:

Antilirium Cyclan Cogex Aricept Exelon Reminyl

Medical Treatment Modalities (cont.)

Pharmaceutical Agents For agitation, aggression, hallucinations, thought disturbances, and wandering: Risperdal Zyprexa Seroquel Geodon

Medical Treatment Modalities (cont.)

Pharmaceutical Agents For depression:

Prozac Zoloft Celexa Paxil

Medical Treatment Modalities (cont.) Pharmaceutical Agents For anxiety (should not be used routinely for prolonged periods):
Chlordiazepoxide (Librium) Alprazolam (Xanax) Lorazepam (Ativan) Oxazepam (Serax)

Medical Treatment Modalities (cont.)

Pharmaceutical Agents For sleep disturbances (for short-term therapy only):

Flurazepam (Dalmane) Temazepam (Restoril)

THE END