Contemporary Psychiatric-Mental
Health Nursing
Third Edition
CHAPTER
14
Cognitive
Disorders
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Learning Objectives
1. Describe the characteristics of and risk factors for cognitive
disorders.
2. Distinguish between delirium and dementia in terms of
symptoms, course, treatment, and prognosis.
3. Apply the nursing process to the care of clients with cognitive
disorders.
4. Identify methods for meeting the needs of people who provide
care to clients with dementia.
5. Provide education to clients, families, caregivers, and
community members to increase knowledge and understanding
of cognitive disorders.
6. Evaluate your feelings, beliefs, and attitudes regarding clients
with cognitive disorders.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
What are Cognitive Disorders?
• Delirium
• Dementia
• Amnestic disorders
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Etiology
• Delirium
– An underlying systemic illness
• Dementia
– Classified as to the cause or area of
brain damage
• Amnestic disorders
– Head trauma, hypoxia, encephalitis,
thiamine deficiency, and substance
abuse
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Theories
• Genetics
– Dementia of Alzheimer’s type
 Binswanger’s disease
– Dementia from Huntington’s disease
– Dementia from Pick’s disease
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Theories (cont'd)
• Infection
– Delirium
– Dementia from Creutzfeldt–Jakob
disease
– Parkinson’s disease
– Amniotic disorders
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Theories (cont'd)
• Vascular insufficiency—Binswanger’s
Disease
– Brain tissue destroyed
– Symptoms absent until 100–200 cc of
brain tissue destroyed
• Underlying systemic illness or injury
– Delirium
– Amnestic disorders
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
DELIRIUM
• is a syndrome that involves a
disturbance of consciousness
accompanied by a change in cognition.
• Delirium usually develops over a short
period, sometimes a matter of hours,
and fluctuates, or changes, throughout
the course of the day
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
S&S
• Difficulty paying attention, are easily distracted and
disoriented, and may have sensory disturbances such as
illusions, misinterpretations, or hallucinations.
• An electrical cord on the floor may appear to them to be a
snake (illusion).
• They may mistake the banging of a laundry cart in the
hallway for a gunshot (misinterpretation).
• They may see “angels” hovering above when nothing is
there (hallucination).
• Experience disturbances in the sleep–wake cycle, changes
in psychomotor activity, and emotional problems such as
anxiety, fear, irritability, euphoria, or apathy
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Etiology
• Delirium almost always results from an
identifiable physiologic, metabolic, or
cerebral disturbance or disease or from
drug intoxication or withdrawal
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Treatment
• Sedation to prevent inadvertent self-injury may
be indicated. An antipsychotic medication, such
as haloperidol (Haldol), may be used to decrease
agitation.
• Sedatives and benzodiazepines are avoided
because they may worsen delirium.
• Clients with impaired liver or kidney function
could have difficulty metabolizing or excreting
sedatives.
• The exception is delirium induced by alcohol
withdrawal, which usually is treated with
benzodiazepines
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Dementia
• is a mental disorder that involves
multiple cognitive deficits, primarily
memory impairment, and at least one
of the following cognitive disturbances.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Treatment
• Treat the underlying cause;For example,
the progress of vascular dementia, the
second most common type, may be halted
with appropriate treatment of the
underlying vascular condition (e.g.,
changes in diet, exercise, control of
hypertension, or diabetes).
• Improvement of cerebral blood flow may
arrest the progress of vascular dementia
in some people
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Amnestic disorders
Are characterized by a disturbance in
memory that results directly from the
physiologic effects of a general medical
condition or the persisting effects of a
substance such as alcohol or other
drugs
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
S&S
• The memory disturbance is sufficiently
severe to cause marked impairment in
social or occupational functioning and
represents a significant decline from
previous functioning.
• Confusion, disorientation, and
attentional deficits are common
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Differentiating Types of
Cognitive Disorders
• Delirium
– Acute confusional state characterized by
disruptions in thinking, perception, &
memory
• Dementia
– Chronic state characterized by declines
in multiple cognitive areas, including
memory
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Differentiating Types of
Cognitive Disorders (cont'd)
• Amnestic disorders
– Uncommon cognitive disorder
characterized by amnesia
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Delirium and Dementia Differences
• Delerium
– Fluctuating consciousness
– Ability to pay attention/respond
– Short-lived
– Rapid onset
– Can be linked to a cause
– May be reversible
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Delirium and Dementia
Differences (cont'd)
• Dementia
– Stable levels of consciousness
– Steady attentiveness
– Chronic
– Slow insidious onset
– Undetermined cause
– Generally irreversible
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
difference between dementia and
amnestic disorders
• The main difference between dementia
and amnestic disorders is that once the
underlying medical cause is treated or
removed, the client’s condition no
longer deteriorates
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Depression
• Depression can be masked by
symptoms suggestive of dementia
• The term pseudodementia is used to
describe the reversible cognitive
impairments seen in depression
• Pseudodementia is characterized by an
abrupt onset, rapid clinical course, and
client complaints about cognitive
failures
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Assessment
• Delirium
– Fluctuating levels of consciousness
– Disorientation and sundowning is a
psychological phenomenon associated
with increased confusion and
restlessness in patients with some form
of dementia
– Impaired reasoning
– Poor attention span
– Altered sleep–wake cycle
– Alternating patterns of motor behavior
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Assessment (cont'd)
• Dementia
– Memory impairment
– Cognitive impairment
• Aphasia, which is deterioration of
language function.
• Apraxia, which is impaired ability
to execute motor functions despite
intact motor abilities
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
• • Agnosia, which is inability to
recognize or name objects despite
intact sensory abilities
• • Disturbance in executive
functioning, which is the ability to
think abstractly and to plan, initiate,
sequence, monitor, and stop complex
behavior
– Poor judgment
– Decline in previous abilities
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Interventions for Delirium
• Introduce self and call client by name
at each contact
• Maintain face-to-face contact
• Use short, concrete phrases
• Keep room well lit
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Interventions for Delirium (cont'd)
• Keep environmental noise low
• Set limits on behavior
• 1:1 staffing as needed
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Interventions for Dementia
Gently orient the client
Educate family about home safety
Maintain optimal nutrition
Bowel and bladder training
Utilize nonverbal forms of
communication
• Structure the environment to support
cognitive functions
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Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Supporting Optimal Memory
Functioning
• Environmental reminders
• Reminiscence activities: involves
exchanging memories with the old and
young, friends and relatives with HCPs
• Triggers for semantic memory
• Support cognitive strengths
• Assist to cope with cognitive deficits
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Caregiver Difficulties
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Wandering behaviors
Sundowning disorientation
ADLs
Medication management
Burnout and fatigue
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Caregiver Resources
• Family meetings
• Alzheimer’s Disease and Related
Disorders Association (ADRDA)
• Caregiver support groups
• Attorney
• Identify community resources
• ID bracelet for the client
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff
Self-Awareness
• Caring for clients with cognitive
disorders can be difficult and frustrating
at times.
• Self-awareness inventory in your text
• The responses are designed to help you
to become more successful in working
with cognitively impaired clients and
their families.
Contemporary Psychiatric-Mental Health Nursing, Third Edition
Carol Ren Kneisl • Eileen Trigoboff