Ch. 23- Neurocognitive Disorders (NCD)
Clinically significant deficit in cognition or memory→ notable change from previous
level of functioning
NCDs are syndromes called major or minor NCD
Delirium
Dementia= cognitive decline observable by others
Alzheimer’s disease= a form of dementia
Delirium= a mental state; ACUTE disturbance in attention & awareness; change in cognition→
dev abruptly over short-time period
S/s:
Difficulty sustaining & shifting attention
Very distractible→ must repetitively remind pt to focus
Disorganized thinking
Speech→ rambling, irrelevant, pressured, incoherent
Unpredicatably switches from subject to subject
Impaired reasoning, ability & goal directed behaviors
Disorientation to time & place→ A&Ox2
Memory impairment; evident
Sleep/wake cycle disturbances
Illusions
Hallucinations
Predisposing Factors→ medical, sx, neurological conditions; 65+ = high risk of
predisp. delirium
Systemic infections
Febrile illness or hyperthermia→ HIGH temp
Metabolic disorders
Lyte imbalances, hypercarbia, hypoglycemia, or hyponatremia
Hypoxia & chronic obstructive pulmonary disease (COPD)
Hepatic failure or renal failure
Head trauma
Seizures
Brain abscess or brain neoplasms
Stroke
Nutritional deficiency
Uncontrolled pain
Heat stroke
Orthopedic and cardiac surgeries
Social isolation, emotional stress, physical restraints, admission to an intensive
care unit
Depression
Falls
Elderly abuse
Dementia= Major NCD
Progressive decline in cognitive ability→ brain cells die/stop functioning
Significantly impairs social & occupational functioning
5.8 million in U.S. w Alzheimer’s→ incident increases w age
10% ages 65+
15th cause of death in age group
⅔ are women
By 2050, ppl w AD (ages 65+) will triple
Greatest risk factor= AGE
Alzheimer’s disease (AD) is NOT a normal part of aging
AD Occurs d/t:
1) Formation of amyloid plaques→ contribute to degradation of nerve cells in the
brain
2) Neurofibrillary tangles= insoluble twisted fibers found inside brain cells
Tangles of protein= “tau”; they transport nutrients/other imp substances
from one part of nerve cell to another
In AD, tau becomes abnormal & COLLAPSES→ nutrients unable to
transfer from one part of nerve cell to another :(
3) The gene apolipoprotein E (APOE); up to 4 genes
APOE0, APOE1, APOE2, etc.→ increases risk of AD
APOE= protein fragments that the body produces & normally eliminates
In AD, the fragments accumulate & become insoluble plaques
2 Theories of how AD is acquired:
1) NT acetylcholine (ACh) in etiology of AD
2) Hx of head trauma at risk for AD
Dx Labs
Blood & urine→ test for various infections
LFTs→ r/o hepatic disease
Glucose tests→ r/o diabetes or hypoglycemia
Lytes→ r/o imbalances
Thyroid tests→ r/o hypothyroidism
Vitamin B12→ r/o nutritional deficiencies
Drug & alcohol screening→ r/o presence of toxic substances
Rapid Plasma Reagin (RPR)→syphilis screening; if pt is at high risk for conditions
HIV→ if pt is at high risk for conditions
S/s:
Global cognitive impairment
Judgment, insight, language, tasking & recognition
Executive functions decreased
Can’t plan, organize, sequence & abstract
Conventional rules of social conduct disregarded
Inappropriate behavior
Personal appearance/hygiene
Lang. may/may not be affected
Difficulty naming objects
Memory impairment
Ex: Amnesia
Gradual personality changes
Aphasia= inability to speak
Broca’s→ lang production
Wernicke’s→ lang comprehension
Difficulty finding correct word→ reduced to few words→ babbling
Apraxia= loss of purposeful movements/gestures (despite desire to perform them)
Unable to perform familiar tasks
Ex: can’t dress themselves properly→ put arms in pants, wear jacket upside down
Agnosia= inability to interpret sensations→ usu result of brain damage
Ex: Auditory agnosia= inability to recognize familiar sounds
A telephone ringing
Ex 2: Visual/tactile agnosia= inability to recognize familiar objects
Don’t know what a cup, magazine, pencil, or toothbrush is
Agraphia= loss of ability to write
Hyperorality= inserting inappropriate objects into mouth
Hypermetamorphosis= compulsion to touch every object in sight
SIDE NOTE: Depression in older adults can mimic early stages of AD
Ex:
Changes in ADLs→ depression has MORE changes
Decreased social activities
Family hx
Complains of memory loss
AD will NOT complain
Defense Mechanisms
Unconscious way of reducing anxiety/maintaing self-esteem
Many dementia/AD pts use this in early stages of disease
To compensate for memory loss
Types:
Denial= Pt AND family members→ refuse to believe that changes like memory
loss are happening; even if changes are obvious to others
Confabulation= Pt unconsciously makes up stories; NOT lying→ production of
false memory w/out intent of deceit
Rationale: protects pts ego & reduces anxiety
Unconscious attempt to save self-esteem→ prevents pt from admitting
he/she doesn’t remember occasion
Perseveration= repeating phrases or behaviors that one has already said
Ex: Grandma remember the time we went to Italy & ate that gelato?
“Yes! That gelato was so good during the Italy trip!” - in reality, she
cannot remember or expand on the event.
Avoidance of questions
Stages of AD
Stage 1: No apparent symptoms
Stage 2: Very mild changes
Stage 3: Mild cognitive decline
Stage 4: Moderate cognitive decline
Stage 5: Moderately severe cognitive decline
Stage 6: Severe cognitive decline
Delusions often apparent
Ex: “It’s 8AM, I need to go work!” → Pt still thinks they work
Psychomotor s/s:
Wandering, obsessiveness, agitation, aggression
Sundowning= agitation & aggression worsens in late afternoon/evening
Stage 7: Very severe cognitive decline
Muscle immobility requires assistance with repositioning/movement
Lack of appetite/awareness of meal
Difficulty chewing/swallowing
CAUTION: pt can die via choking/aspiration
Must help/assist pt w eating
Body jerking→ risk for injury
Outcomes for AD & Delirium
R/t cognitive & pyschomotor functioning
Important to ensure safe environment
No physical injury
No harm to self or others
Maintain reality orientation to the best of capability
Communicates w consistent caregiver
Fulfills ADLs with assistance
If pt unable to fulfill ADLs→ needs met by caregiver
Discusses positive aspects about self/life
Nursing Interventions for AD/Delirium
Prevention Injury
Arrange furniture to accommodate pts needs
Ex: frequently used items near pt for easy access
Keep bed in lowest position
Room Near RN Station
Need to closely monitor
1:1 may be necessary for delirious pt
Keep dangerous items at RN’s station
Agitated Pt (ex: in mental health hospital)
Maintain low stimulation environment
Inform family how we care for agitated/aggressive pts→ for family understanding
Antipyschotics
Remain calm & undemanding***
Avoid pressuring pt to perform activities they are refusing
Reasoning w pt can increase agitation
Dance/ Rhythmic movement therapy= evidence-based intervention to
reduce anxiety & agitation
Helpful in SLOWING progression of AD :)
Wandering pts
Reasons why pts may wander:
Increased stress/anxiety or restless/agitation
Cognitive/memory decline
Pt is searching for something that looks familiar! :(
Goal= keep pt SAFE
Structured schd of recreational activities, strict feeding & toileting schd
Provide safe/enclosed place→ pacing & wandering
Walk w pt & gently redirect back to care unit
Ensure outdoor exits are electronically controlled
Disoriented pts
CONSISTENCY is key
Show pt old photographs; utilize reminiscence therapy
Use clocks & calendars w large numbers→ easy to read
Place large, colorful signs on doors→ identify pts room, bathroom, activity
rooms, dining rooms, and chapel.
Allow many personal items
Ex: Old familiar chair→ can provide comfort
Encourage fam/friends to be involved in pts care→ promotes feelings of
security & orientation
Provide pt w radio, television, & music if they are diversions the pt enjoys
Adds feeling of familiarity to environment
Control noise level to prevent excess stimulation
Keep pt oriented to reality***
There is criticism for pts w moderate-severe AD
Reality orientation= constant re-learning of material→ can lower
pts mood & self-esteem :(
Better alternative= validation therapy :)
Positive effects on pts that are: disoriented, agitated, irritable, or
have apathy (lack of interest)
Pt centered approach***
Ex: Agitated pt says “that lady out there stole my watch! She goes into peoples
rooms and takes their watches! We call her sticky fingers”
Reality orientation= “No, that lady didn’t steal your watch. She doesn’t
like to take things. Don’t call her sticky fingers, that's kind of mean.”
Validation therapy= “That watch seems very important to you. Have
you looked around the room for it?”
Pt: “My husband gave it to me, he would be so upset that its gone!
I’m afraid to tell him”
RN: “Im sure you miss your husband very much. Tell me what it
was like when you were together. What kind of things do you do
for fun?”
Validating pts feeling of missing her husband; not denying that the
watch wasn’t stolen
Maintain consistency of staff & caregivers
Pts w Delusions & Hallucinations
Minimize focus on delusional thinking
Never argue a point w the pt
Do not ignore reports of hallucinations when it is clear that the pt is
experiencing them
Ensure pts hearing aid is working properly; ensure faulty sounds are not being
emitted
Check eyeglasses to ensure pt is wearing his/her own glasses
Provide reassurance that pt is safe
Never argue that the hallucination is not real
Distract the patient
Assess whether or not the hallucinations are problematic for pt
Ex: Auditory commands→ “the voices are telling me to kill him”
Inability to Process Verbal Communication
Use calm & reassuring approach when interacting with pt
Use simple words, speak slowly & distinctly, keep face-to-face contact w pt
Always identify yourself to pt & call him/her by name at each meeting
Only ask one question (or give only one direction) at a time
Too many questions→ overwhelms pts
You may need to rephrase question→ if not clear for pt
Always approach pt by the front
Unexpected approach/touch can startle pt or promote aggression
Maintain consistency of staff and caregivers
If pt becomes verbally aggressive, remain calm & provide validation for his/her
feelings
When appropriate, use touch & affection to communicate
Self-Care Deficit→ think of depression; pyschomotor retardation; cognitive decline
Allow plenty of time to complete tasks
Provide guidance & support for independent actions
Offer pt assistance
Provide simple, structured schd
Ex: Activities that do not change from day to day
Ensure that ADLs follow pts usual routine as closely as possible
Minimize confusion by providing consistency in daily tasks
Medications→ No cure for AD :(
Mild to Moderate Stages:
1) Donepezil (Aricept)
Gives higher production of ACh at nerve synapse→ helps improve
ability to perform self-care :)
Slows cognitive decline in AD
2) Rivastigmine (Excelon)
3) Galantomine (Razadyne)
S/s for all 3:
Dizziness
GI upset
Headaches
Insomnia→ specifically for Donepezil
Moderate to Severe:
Memantine (Namenda)
MOA: blocks entry of Ca++ into nerve cells→ slows down brain cell
death
Slows progression of cognitive decline
S/s:
Dizziness
Headaches
Constipation
Atypical antipsychotics→ some physicians do NOT prescribe; controversy**
Hx: Controls agitation, aggression, hallucinations (in schizophrenia)
But can also control these s/s in Dementia/AD
HOWEVER:
FDA has black-box warning bc INCREASED risk of death in elderly pts
CV related
Must ensure pt/family is OKAY w the risks of atypical
antipsychotics
SSRI→ helps w mood & anxiety
Alternative therapies:
Estrogen therapy: may prevent AD, but will not decrease preexisting cognitive
deficits→ can also cause DVT :(
Gingko biloba= enhances memory, BUT risk of drug-to-drug interactions,
bleeding or seizures
Delirium vs. Dementia
Delirium
Dementia
Acute; rapid; short period (hrs or days)
Progressive; gradual deterioration (months or years)
Distractible
Agitation
Restless, agitation varies
Wandering, aggression
VS may be unstable
VS stable
Rapid personality changes
Gradual personality changes
LOC fluctuates
LOC unchanged
Speech is rambling, pressured & incoherent
May not speak at all
Attention waxes & wanes
Stable attention
Hallucinations, illusions
Hallucinations, delusions, sundowning
Short lived, reversible
Irreversible
Multiple causes
Usu organic cause
Medical emergency→ must determine cause