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ZARRAH ROSE S. ALIANZA BSN3A ^_^

CHAPTER 21 COGNITIVE DISORDERSCognition=brains ability to process, retain & use information

Cognitive abilities=include reasoning, judgment, perception, attention

Cognitive disorder=is a disruption or impairment in higher level functions of the brain

DELIRIUMA syndrome that involves a disturbance of consciousness accompanied by a change in cognition

Develops over a short period of time

Clients have difficulty paying attention, are easily distracted and disoriented and may have sensory disturbances such

as illusions, misinterpretations or hallucinationsDSM-IV-TR Diagnos

tic criteria: Symptoms of Delirium

difficulty with attentioneasily distractibledisorientedsensory disturbancescan have sleep-awake disturbanceschanges in psychomotor activity

anxiety, fear, irritability, euphoria or apathy

EtiologyMOST COMMON CAUSES OF DELIRIUM

physiologic or metabolic hypoxemia, electrolyte disturbances, renal or hepatic failure, hypoglycemia,hyperglycemia, dehydration, sleep deprivation, thyroid or glucocorticoiddisturbances, thiamine or Vitamin B12 deficiency, vitamin C, niacin, or proteindeficiency, cardiovascular shock, brain tumor, head injury and exposure to

gasoline, paint solvent, insecticides and related substances

infection systemic: meningitis, encephalitis, HIV, syphilis

drug-related intoxication: anticholinergics, lithium, alcohol, sedatives and hypnotics;withdrawal: alcohol, sedatives, hypnotics; reactions to anesthesia, prescription

medication or illicit drugs

Risk factors include:

increased severity of physical illness

older age

baseline cognitive impairment

Treatment and Prognosis

Identify and treat any causal or contributing medical conditions

Psychopharmacology

Sedation=to prevent inadvertent self-injury

Antipsychotic medications such as haloperidol (Haldol)=used to decrease agitation

sedatives and benzodiazepines are avoided because they may worsen delirium

Other Medical Treatment

adequate nutritious foods and fluid intake

intravenous fluids or even total parenteral nutrition if clients physical condition has deteriorated and cannot

eat nor drink

physical restraints so that needed medical treatments can continue

DRUGS CAUSING DELIRIUManticonvulsants, anticholinergics, antihistamines, antihypertensives, antineoplastics, antipsychotics, aspirin,barbiturates, benzodiazepines, cardiac glycosides, cimetidine (tagamet), hypoglycemic agents, insulin, narcotics,propranolol (inderal), reserpine, steroids, thiazide diuretics

APPLICATION OF THE NURSING PROCESS

Assessment

History

obtain information related to medical illness, alcohol or other drugs

information about drugs should include prescribed medications, alcohol

General Appearance & Motor Behavior

have disturbances of psychomotor behavior

may be restless, hyperactive, frequently pricking at bedclothes or mak

attempts to get out of bed

may have slowed motor behavior, appearing sluggish and lethargic with

speech becomes less coherent and more difficult to understand

may perseverate on a single topic or detail

clients may call out or scream especially at night

Mood & affect

often have rapid, unpredictable mood shifts

wide range of emotional responses is possible such as anxiety, fear, irrita

fearful and feel threatened, they may become combative to defend thems

Thought process & content

thought processes often are disorganized and make no sense

thought may also be fragmented (disjointed and incomplete)

may exhibit delusions, believing their altered sensory perceptions are rea

Sensorium & intellectual process

initial sign is an altered level of consciousness that is seldom stable

oriented to person but frequently disoriented to time and place

demonstrate decreased awareness of the environment

noises, people or sensory misperceptions easily distract them cant focus, sustain or shift attention effectively and there is impai

memory

frequently experience misinterpretations, illusions and hallucinations

Judgment & Insight

judgment is impaired

cant perceive potentially harmful situations or act in their own best inter

insight depends on the severity of the delirium

with mild delirium may recognize that they are confused

with severe delirium may have no insight to the situation

Self-concept

often are frightened or feel threatened

may feel helpless or powerless to do anything to change it

may feel guilt, shame, and humiliation

Roles & Relationships

unlikely to fulfill their roles

have no longstanding problems with roles or relationships

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Physiologic consideration

disturbed sleep-wake cycles, falling asleep, daytime sleepiness , nighttime agitation or even a

complete reversal of the usual daytime waking/nighttime sleeping patternData Analysis

Nursing diagnosis commonly used when working with clients who somatize:

risk for injury

acute confusion

disturbed sensory perception

disturbed thought process

disturbed sleep pattern

Outcome Identification

Treatment outcomes may include the following:

client will be free of injury

client will demonstrate increased orientation and reality contact

client will maintain an adequate balance of activity and rest

InterventionNURSING INTERVENTIONS FOR DELIRIUM

1. promoting clients safetyteach client to request assistance for activitiesprovide close supervision to ensure safety during these activitiespromptly respond to clients call for assistance

2. managing clients confusionspeak to client in calm manner

allow time for client to comprehend and respondallow client to make decisionsprovide orienting verbal cues when talking to clientuse supportive touch if appropriate

3. controlling environment to reduce sensory overloadkeep environmental noise to minimum

monitor clients response to visitorsvalidate clients anxiety and fears but do not reinforce misperceptions

4. promoting sleep and proper nutritionmonitor sleep and elimination patternmonitor food and fluid intakeprovide periodic assistance to bathroom if client does not make requestsdiscourage daytime napping to help sleep at night

encourage some exercises during day

CLIENT / FAMILY EDUCATION FOR DELIRIUM

Monitor chronic health conditionsVisit physician regularlyAvoid alcohol & recreational drugs

DEMENTIAA mental disorder that involves multiple cognitive deficits, primarily memory impairment and at least one of the

following cognitive disturbances:

1. Aphasia= deterioration of language function

2. Apraxia=impaired ability to execute motor functions

3. Agnosia=inability to recognize or name objects4. Disturbance in executive functioning=ability to think abstractly and to plan, initiate, sequence, monitor and stop

complex behavior

Memory impairment=early sign of dementia

Echolalia=echoing what is heard

Palilalia=repeating words or sounds over and overDSM-IV-TR Diagnostic criteria: Symptoms of Dementia

Loss of memoryDeterioration of language functionLoss of ability to think abstractly and to plan, initiate,

seque

nce, monitor or stop complex behaviors

Onset and Clinical Course

Dementia is described in stages as follows:

Mild= forgetfulness is the hallmark of mild dementia

Moderate=Confusion is apparent along with progressive memory loss.

Severe= personality and emotional changes occur. Forget names of his/ her sp

require assistance in ADL Etiology

Most common types of dementia:

Alzheimers disease

progressive brain disorder that has a gradual onset but causes an increasi

including loss of speech, loss of motor function and profound personality

Abnormal APOE gene and linkages to chromosomes 21, 14 and 19

enlargement of third & fourth ventricles

Vascular dementia

symptoms similar to Alzheimers but onset is abrupt, following by rapid

plateau, or leveling off period

Picks Disease

degenerative brain disease that affects the frontal and temporal lobes

Early signs include personality changes, loss of social skills and inhibiti

and language abnormalities

50 60 years old (onset) and 2-5 years (death)

Creutzfeldt- Jakob disease

a CNS disorder that develops in 40- 60 years old.

HIV infection

invasion of nervous tissue by HIV

Parkinsons disease

slowly progressive neurologic condition characterized by tremor, rigidity

postural instability.

Results from loss of neurons of basal ganglia.

Huntingtons disease

inherited, dominant gene disease that involves cerebral atrophy, demyeli

brain ventricles.

There are choreiform movements that are continuous during waking hour

contortions, twisting, turning and tongue movements.

Head trauma

Treatment and Prognosis

Acetylcholine, dopamine, norepinephrine are decreased in dementia

Treatments include acetylcholine precursors, cholinergic agonists and cholinestera

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Cholinesterase inhibitors= have modest therapeutic effects and temporarily slow progress of dementia.

Tacrine ( Cognex)- elevates liver enzymes

Donepezil ( Aricept)

Rivastigmine (Exelon)

Galantamine (Reminyl)

Antipsychotics: Haloperidol ( Haldol), Olanzapine (Zyprexa), Risperidone (Risperdal)

Lithium carbonate, Carbamazepine ( Tegretol) and Valproic acid ( Depakote)= stabilize affective lability

and diminish aggressive outbursts

Benzodiazepines=may cause delirium and worsen compromised cognitive abilitiesDRUGS USED TO TREAT DEMENTIA

Name Nursing considerations

Tacrine ( CognexDonepezil ( Aricept)Rivastigmine (Exelon)Galantamine (Reminyl)

Monitor liver enzymesMonitor for nausea, diarrhea & insomniaMonitor for nausea, vomiting, abdominal painMonitor for nausea, vomiting,

loss of appetite

APPLICATION OF THE NURSING PROCESS

Assessment

Mental status examination=provide information about the clients cognitive abilities

History

General Appearance & Motor Behavior

Slurred speech; total loss of language function

Apraxia=loss of ability to perform familiar tasks such as combing hair

Cannot imitate tasks others demonstrate; gait disturbance; neglect hygiene

Mood & affect

Anxiety and fear; not express feelings; labile mood; emotional outbursts; anger and hostility;

catastrophic emotional reactions; withdrawal, lethargic, apathetic, little attention

Thought process & content

Loss ability to plan, sequence, monitor, initiate or stop complex behavior

Delusions of persecutions

Sensorium & intellectual process

Confabulation= make up answers to fill in memory gaps

Agnosia=another hallmark of dementia

Lose of visual spatial relationships

Impaired attention span, confused; disoriented

Hallucinations ( usually visual hallucinations)

Judgment & Insight

Poor judgment; insight is limited

Underestimate risks and unrealistically appraise their abilities

Self-concept

Angry or frustrated with themselves

Sadness at their bodies for getting old Loss of self- awareness

Fail to recognize own reflections

Roles & Relationships

Work performance suffers; deteriorating roles

Inability to participate in meaningful conversations or social events

Family members assume caregiver roles; role reversal

Physiologic consideration

Disturbed sleep- wake cycles

Ignore hunger or thirst

Bladder and bowel incontinence

Neglect bathing and grooming

Data Analysis

Nursing diagnosis commonly used:

risk for injury

disturbed sleep pattern impaired memory

Outcome Identification

Treatment outcomes may include the following:

client will be free of injury

client will function as independently as possible

client will maintain an adequate balance of activity and rest

InterventionNURSING INTERVENTIONS FOR DEMENTIA

1. Promoting clients safety

Offer unobtrusive assistanceIdentify environmental triggers

2. Promoting adequate sleep, proper nutrition and hygiene and activityPrepare desirable foodsMonitor bowel eliminationRemind client to urinate; provide pads or diapers

Encourage mild physical activity such as walking

3. Structuring environment and routineEncourage to follow regular routine and habitsMonitor amount of environmental stimulation and adjust when needed.

4. Providing emotional supportBe kind, respectful, calmUse supportive touch when appropriate

5. Promoting interaction and involvementPlan activities geared to clients interests and abilitiesReminisce the pastRemain alert to nonverbal behavior

Promoting interaction and involvement

Reminiscence therapy=thinking about or relating personally significant p

Distraction=shifting the clients attention and energy to a more neutral to

Time away=leaving clients for a short period and then returning to them

Going along=providing emotional reassurance without correcting their mCAREGIVER EDUCATION FOR DEMENTIA

Encourage clients to follow usual routingEncourage independence as much as possibleEncourage

clients to participate in activities of interest

Mental Health Promotion

People with elevated levels of homocysteine are at increased risk for dementia .

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Folate, vit. B12 , and betaine reduce plasma homocysteine levels

Participate in brain- stimulating activities such as reading

Related Disorders

Amnestic disorders=disturbance in memory that results directly from physiologic effects of a general

medical condition or alcohol and drugs

Korsakoffs syndrome=alcohol- induced amnestic disorder results from a chronic thiamine or vitamin B

deficiencyCOMPARISON OF DELIRIUM AND DEMENTIA

Indicator Delirium Dementia

Onset Rapi

d Gradual

Duration Brief Progressive deterioration

Level of consc iousness Impai red, f luctua tes Not a ffec ted

Memory Short-term memory impaired Short-then-long term memory impairedS pe ec h S lu rr ed , r um bl in g N or ma l in e ar ly s ta ge , a ph as ia l at er

Thought process Temporarily disorganized Impaired thinking

Perception Visual/tactile hallucinations, delusions Absent; can have paranoia, hallucinations

Mood Anxious , fearful , weeping Depressed & anxious in ear ly s tage

SEE PAGE 479 TO 480 & 492 TO 493 FOR NURSING CARE PLAN

ALZHEIMERS DISEASEprogressive brain disorder that has a gradual onset but causes an increasing decline in functioning, including loss

of speech, loss of motor function and profound personality and behavioral changes.

Abnormal APOE gene and linkages to chromosomes 21, 14 and 19

enlargement of third & fourth ventricle

Acetyl butiryl=increase as Alzheimers progress & found in neuritic plates

Etiology

Genetics

Environment

Onset and Clinical Course

Stages

Stage I=no cognitive impairment

Stage II=mild cognitive decline

Stage III

Stage IV=mild or early stage; supervision is required

Stage V=moderately severe; there is total dependence of client

Treatment

Cholinesterase inhibitors

Dopenezil

Galantamin

Adverse effects

Insomia, fatigue, rashes, nausea & vomiting

Diet

Antioxidant foods Fruit & vegetables like squash & bell peppers

Avoid refined foods like white bread

Drink 6-8 glasses of water daily