Chapter 24: Cognitive Disorders Overview Cognition o Brain’s ability to process, retain, use information o Processes: reasoning, judgment, perception, attention, comprehension, memory Neurocognitive disorders: disruption or impairment in higher level brain functions o Delirium, major NCD, mild NCD, subtypes; dementia Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium #1 Syndrome involving disturbance of consciousness with change in cognition Usually develops over short period Etiology: almost always results from identifiable physiological, metabolic, or cerebral disturbance or disease or from drug intoxication or withdrawal (see Box 24.1) Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium #2 Treatment and prognosis: transient condition, clearing with treatment of underlying cause o Psychopharmacology: sedation, antipsychotic medication o Other medical treatments Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium and Nursing Process Application #1 Assessment o History: medical history, medications (see Box 24.2) o General appearance and motor behavior: disturbed psychomotor behavior, possible speech problems o Mood and affect: rapid, unpredictable shifts o Thought process and content: thoughts may be fragmented. Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium and Nursing Process Application #2 Assessment—(cont.) o Sensorium and intellectual processes: decreased awareness of environment o Judgment and insight: impaired o Roles and relationships: inability to fulfill roles o Self-concept: fear, feel threatened o Physiological and self-care: sleep problems, ignore or fail to perceive internal body cues Copyright © 2020 Wolters Kluwer • All Rights Reserved 1. Question #1 Is the following statement true or false? There is usually an identifiable cause for the development of delirium. Copyright © 2020 Wolters Kluwer • All Rights Reserved 1. Answer to Question #1 True Rationale: Delirium is usually caused by an identifiable physiological, metabolic, or cerebral disturbance or disease or by drug intoxication or withdrawal. Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium and Nursing Process Application #3 Data analysis/nursing diagnoses o Risk for injury o Acute confusion Outcome identification o Freedom from injury o Increased orientation, reality contact o Balance of activity and rest o Adequate nutrition and fluid balance o Return to optimal level of functioning Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium and Nursing Process Application #4 Intervention o Promoting client safety o Managing client’s confusion: orienting cues; speaking in low, clear voice; use of touch; avoiding sensory overload o Promoting sleep, proper nutrition Evaluation Copyright © 2020 Wolters Kluwer • All Rights Reserved Delirium and Community-Based Care Referrals for continued cognitive problems o Home health care/visiting nurses o Rehabilitation program o Adult day care o Residential care o Support groups Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia #1 Progressive cognitive impairment; multiple cognitive deficits; initially memory, later the following may be seen: o Aphasia o Apraxia o Agnosia o Disturbance in executive function Differentiation from delirium (see Table 24.1) Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia #2 Onset, clinical course: o Stages Mild Moderate Severe Etiology: variable causes; decreased metabolic activity found postmortem Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia #3 Types of dementia: o Alzheimer disease o Lewy body dementia o Vascular dementia o Frontotemporal lobar degeneration (Pick disease) o Prion diseases (Creutzfeldt-Jakob disease) o Dementia related to HIV infection o Parkinson disease o Huntington disease o Dementia due to traumatic brain injury Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia #4 Treatment and prognosis o Importance of identifying underlying cause o Progressive types—progressive deterioration until death o Medications for degenerative dementias: cholinesterase inhibitors (see Table 24.2) o Symptomatic treatment for behaviors Antidepressants Antipsychotics Copyright © 2020 Wolters Kluwer • All Rights Reserved 2. Question #2 Is the following statement true or false? A client with dementia experiences changes in his or her level of consciousness. Copyright © 2020 Wolters Kluwer • All Rights Reserved 2. Answer to Question #2 False Rationale: Clients with dementia do not typically experience altered levels of consciousness but do exhibit multiple cognitive deficits along with aphasia, apraxia, agnosia, or a disturbance in executive functioning. Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia and Nursing Process Application #1 Assessment o Mental status examination o History: client may be unable to provide accurate history. o General appearance and motor behavior: aphasia; apraxia; uninhibited behavior o Mood and affect: increasingly labile mood; emotional outbursts o Thought process and content: impaired abstract thinking; delusions of persecution Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia and Nursing Process Application #2 Assessment—(cont.) o Sensorium and intellectual processes: loss of intellectual function; memory deficits; confabulation o Judgment and insight: poor judgment; unrealistically appraise abilities o Self-concept: sadness; loss of self-awareness o Roles and relationships: profoundly affected o Physiological and self-care: disturbed sleep; incontinence; hygiene deficits Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia and Nursing Process Application #3 Data analysis/nursing diagnoses o Risk for injury o Disturbed sleep pattern o Chronic confusion Outcome identification o Freedom from injury o Involvement in surroundings o Interact with others in environment Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia and Nursing Process Application #4 Intervention o Safety o Sleep, proper nutrition, hygiene, activity o Environmental, routine structure o Emotional support o Interaction and involvement Evaluation Copyright © 2020 Wolters Kluwer • All Rights Reserved Dementia and Community-Based Care At least half of all nursing home residents have Alzheimer disease or another dementia-causing illness Home care Adult day care Respite care Residential facilities Skilled nursing home placement Referrals for programs and services Copyright © 2020 Wolters Kluwer • All Rights Reserved Mental Health Promotion Research to identify risk factors for dementia o Elevated levels of plasma homocysteine Measures to decrease risk for Alzheimer disease o Regular participation in brain-stimulating activities o Leisure-time physical activity during midlife o Large social network Copyright © 2020 Wolters Kluwer • All Rights Reserved 3. Question #3 A client makes up answers to fill in memory gaps. The nurse identifies this as which of the following? A. Echolalia B. Palilalia C. Aphasia D. Confabulation Copyright © 2020 Wolters Kluwer • All Rights Reserved 3. Answer to Question #3 D. Confabulation Rationale: Confabulation is the making up of answers to fill in gaps in the memory. o Echolalia is echoing or repeating what is heard; palilalia is repeating words or sounds over and over. Aphasia refers to a deterioration in language function. Copyright © 2020 Wolters Kluwer • All Rights Reserved Role of the Caregiver Majority: women (adult daughters or wives) Needs of caregivers: o Education about dementia, required client care o Assistance in dealing with own feelings of loss o Respite to care for own needs, role strain o Support groups o Assistance from agencies o Support to maintain personal life Copyright © 2020 Wolters Kluwer • All Rights Reserved Self-Awareness Issues Teaching clients with dementia can be frustrating. Feelings of frustration or hopelessness Discuss frustrations with others. May be difficult to deal with feelings about people who will never “get better and go home” Importance of dignity for client and family Copyright © 2020 Wolters Kluwer • All Rights Reserved
