CONCEPT: COGNITION PNE 193 FALL 2020 9/29/20 WHAT IS COGNITION? • The mental action or process of acquiring knowledge and understand through thought, experience, and the senses. • Not a new concept for a college student. DOMAINS OF COGNITIVE FUNCTION • Perceptual motor function • Language • Learning and memory • Social cognition • Complex attention • Executive function • Related terms: • Perception- interpretation of environment based on sensory input • Memory- retention & recall of past experiences & learning (neural subsystems) • Executive function- higher thinking processes allowing for flexibility, adaptability & goal directedness BASIC COGNITION • Intact or Impaired (mild to severe)- temporary or chronic / permanent state • Range of normal for age and culture • Based on a continuum due to change over time • Perception, pattern recognition and attention HIGHER-ORDER COGNITIVE FUNCTION • Learning • Comprehension • Insight problem solving • Reasoning • Decision making • Creativity • Metacognition • Visualspatiol cognition- capacity to comprehend, retain & use visual representation & spatial relationships. • Memory • Declarative episodic memory- conscious learning & recall of information • Declarative semantic memory- memory of knowledge, words & facts- long-term storage • Immediate memory- short term- attention span • Working memory- few chunks of memory retained short period of time • Procedural memory- retention & retrieval of motor skills REVIEW NORMAL PHYSIOLOGIC PROCESS • Human Brain • Units of the brain • Some purposeful and others automated • Limbic system: overlaps cerebrum and diencephalon • Signals integrated and interpreted & triggers a sensory or motor response • Hippocampus: committing information to long-term memory • Table 33.1 AGE-RELATED DIFFERENCES • Infants & children- limbic system undeveloped at birth- Piaget’s theory of cognitive development • Growth of the brain & cognitive function- brain triples in weight during first year & neurons increase until approximately age 2 years. • Birth through childhood & adolescence- neuronal-synaptic connections- milestone achievements in development • Myelination of neurons- needed for efficient neurotransmission of signals between neurons within the brain • Older adults- brain size and number neurons decrease with aging. Highly variable COGNITIVE IMPAIRMENT • NOT a normal part of aging • Indicative of disease • 16 million in United States have some degree of cognitive impairment • Currently more than 5.5 million Americans have dementia caused by Alzheimer’s • Alzheimer’s is the sixth leading cause of death in U.S. but higher for elderly COGNITIVE IMPAIRMENT • Delirium • Neurocognitive Disorders • Cognitive Impairment, Not Dementia • Focal Cognitive Disorders • Intellectual Disability • Learning Disability • Places individual at risk for adverse physical, psychological and social outcomes • Higher risk for injury due to falls • Lack recognition, lack accurate perceptions, & lack capacity for appropriate response to dangerous situations • Complicates disease management • Higher incidence of hospitalization & long-term care • Affect functional ability & capacity for independent living RISK FACTORS • Cross all population groups • Advancing age is primary risk factor • No difference race, ethnicity or gender • Women- overall poor health status, dependency, lack of social support and insomnia • Men- history of stroke or diabetes • Pediatrics- genetic syndromes, toxicity & metabolic conditions, maternal disease, hypoxic ischemic injury during labor & brain malformation INDIVIDUAL RISK FACTORS • Personal behaviors: substance abuse, high-risk activities, omission of basic safety measures; Accidental injuries or trauma • • • • Environmental Exposure- toxic substances- lead exposure, pesticides Physical Disability & Reduce Mobility Health Conditions Congenital & Genetic Conditions – Present at birth• Fetal alcohol syndrome or Drug exposure • Birth injuries- Cerebral palsy • Chromosomal abnormalities- Down syndrome or fragile X syndrome, phenylketonuria & galactosemia • Huntington’s disease – usual presents in 40’s ASSESSMENT – BOX 33.1 • • • Vary with stage of development • • Infants & children- prenatal & birth history & three generation family health history Routine observations by healthcare providers, patient self-report and report of family & others History- begin with assessing consciousness, speech pattern & content, noting memory, logic & judgment; assess trauma, substance abuse, & medications, environmental or occupational exposure to hazards Mental status assessment- include appearance (relaxed, coordinated & smooth), behavior (awake, alert & aware- flat expression associated with dementia- watch for confabulation) & cognitive function ASSESSMENT OF COGNITIVE FUNCTION • Orientation to person, place, time, attention, memory, judgment, insight, spatial perception, calculation , abstract reasoning, thought process, and content • MMSE – Mini-Mental Status Exam- standardized cognitive assessment tool • Three words Three shapes test- memory, recall, recognition • Delirium- Confusion Assessment Method (CAM) • No lab tests for diagnosis but may determine presence of associated disease • Formal neuropsychometric testing CLINICAL MANAGEMENT • Primary Prevention • • • • • Healthy Lifestyle Genetic Counseling Educate healthcare providers about practice changes: Secondary Prevention (Screening) • General Management Strategies • • • • Collaborative Interventions • Rest, sleep, fluid intake, nutrition, elimination, pain control & comfort Environmental stimulation Safety Pharmacologic Agents- Cholinesterase inhibitors: Donepezil, rivastigmine, galantmine, glutamate receptor antagonist:memantine Family & caregiver support INTERRELATED CONCEPTS • Glucose Regulation • Mobility • Nutrition • Gas Exchange • Perfusion • Intracranial Regulation • Fluid & Electrolytes • Acid-Base Balance • Functional Ability and Development EXEMPLARS • Delirium • Alzheimer Disease • Lewy Body Dementia • Vascular Dementia • Fetal Alcohol Syndrome • Down Syndrome INFORMATICS/ TECHNOLOGY • Technology: knowledge & use of tools, machines, materials & processes to help solve human problems- Health IT • Informatics: Process, management & retrieval of information • Health Informatics: health date storage, analyzed and disseminated • Electronic Health Record (HER) • Mobile Health tools= Fitbit, personal health records & portals, Glucose monitors • Health Information Exchange-Sharing & Communication HEALTH IT • • • • Hardware & Software • • • Policies-Meaningful use of EHRs- Documentation, Billing, Patient Use Digital Tools: tablets, smartphones & computers Mobile applications: food aps, glucose monitors Standardized Information Systems & Terminology- communicating care to interprofessional team & exchanging health information Privacy & Security – HIPAA- Health Insurance Portability & Accountability Act Informatics Workforce – 2006 TIGER –Technology & Informatics Guiding Education Reform initiative; QSEN- determined informatics competences at prelicensure and Graduate levels. INFORMATICS LINKS • Information Science • Computer Science • Cognitive Science • Organizational Science- complex & adaptive This Photo by Unknown Author is licensed under CC BY-SA-NC APPLICATION TO NURSING • Florence Nightingale (1863)- “Show how money being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good.” • 1970’s – widespread use of information and communication technologies • IOM, 2000, To Err Is Human: Building a Better Health System- Healthcare in need of reform – Improved information infrastructure needed • 2009 American Recovery & Reinvestment Act- CMS reimbursement incentive for meaningful uses of EHRs• Federal Health Information Technology Strategic Plan (2015-2020)- health information accessible when & where needed to improve & protect people’s health & well being. • Pew Research Center since 2002- increased access to broadband & internet; mobile connectivity; presence of social media & social networks INFORMATICS IN NURSING PRACTICE • EHRs for gathering and retrieval of information • Nursing documentation- evidence-based practice guidelines & alerts • Meaningful Use- access to patients and other care providers for decision making • Across professional, patients/consumers, and healthcare institutions- connected healthcare delivery system • Robust infrastructure for broad-based health information exchange • Better coordination of care INTERRELATED CONCEPTS • Clinical Judgment • Leadership • Communication • Collaboration • Safety • Evidence • Care Coordination • Health Care Quality • Ethics • Health Policy • Health Care Law EXEMPLARS OF TECHNOLOGY & INFORMATICS • Clinical Informatics • • • • • • • • • • • • • • • • • • • • Bar code medication administration Clinical decision support systems Computerized acuity systems Computerized nursing documentation Computerized provider order entry systems Disease/patient registries Electronic health record systems Electronic prescribing Health information exchange Telehealth tools Consumer Health Informatics • • Patient-generated health data tools Social media tools for online support Health & Wellness apps Chronic disease management apps Home & self-care monitoring devices Smart devices & sensors Public Health Informatics Biosurveillance Tools • Population health management tools Personal health records & patient portals Geographical information system tools, Predictive modeling tools, Disaster preparedness tools, Immunization registries Bioinformatics Tools • Homology& similarity tools, Protein function analysis, Structural analysis & sequence analysis tools, Data missing & Data analytics tools CREATIVITY DISCUSSION • Pick any area of informatics. • In the discussion board, present a new potential use for the topic in health care. Support your idea. About half a page, not a book • Respond to at least 2 topics presented by your classmates – Not just like or not. TEST: 10/6/20 AT 3 PM IN HP 345 ALL MATERIAL COVERED SINCE LAST TEST
