Chapter 21: Cognitive Disorders Cognition involves the brains ability to process, retain, and use information.

Cognitive abilities include reasoning, judgment, perception, attention, comprehension, and memory. Disruption of these functions impairs the persons ability to make decisions, solve problems, interpret the environment, and learn new information. Delirium Delirium is a syndrome that involves disturbance of consciousness accompanied by a change in cognition. It develops over a short period of time and fluctuates over time. It causes difficulty in paying attention, distractibility, and disorientation. Sensory disturbances include illusions, misinterpretations, hallucinations, disturbances in the anxiety, fear, irritability, euphoria, apathy. 10% to 15% of persons hospitalized for a general medical condition have delirium. It is more common in acutely ill geriatric clients and children with high fevers or taking certain medications. Etiology Delirium is caused by an underlying physiologic, metabolic, or cerebral disturbance, or by drug intoxication/withdrawal. Treatment and Prognosis Treatment of the underlying medical condition will usually resolve delirium. Clients with head injury or encephalitis may have cognitive, emotional, or behavioral impairment due to brain damage from the disease or injury. Delirious clients who are quiet and resting need no other medication for delirium. Those who are restless or a safety risk may require low-dose sleep/wake cycle,

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antipsychotic medication. Sedatives and benzodiazepines may worsen the delirium. Alcohol withdrawal is managed medically with benzodiazepines. IV fluids or total parenteral nutrition may be needed. Occasionally restraints are necessary so that tubes and catheters arent pulled out. Use judiciously and for short periods because restraints may increase agitation. Application of the Nursing Process: Delirium Assessment Assessment is ongoing and continuous because the clients level of consciousness and orientation may fluctuate. Thorough history of prescribed and OTC medications needed General appearance and motor behavior: may be restless, picking at covers, agitated, getting out of bed, or sluggish and lethargic; speech is less coherent as delirium worsens. Mood and affect: Client has rapid and unpredictable mood shifts with a wide range of emotions. Thought process and content: difficult to assess thought process accurately due to disorientation and impaired cognition. Sensorium and intellectual processes: sensory misperceptions, disorientation, confusion, lack of attention and concentration Impaired judgment and insight: impaired judgment, varied insight Roles and relationships: usually no long-term effect unless previous problems existed Self-concept: how the person sees him or her self Physiologic and self-care considerations: trouble sleeping, may ignore body cues, such as hunger, thirst, or the urge to urinate or defecate

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Data Analysis Primary nursing diagnoses include: Risk for Injury Acute Confusion

Additional diagnoses based on individual client assessment: Disturbed Sleep Pattern Disturbed Thought Processes Disturbed Sensory Perceptions Risk for Imbalanced Nutrition Sensory-Perceptual Alterations Risk for Deficient Fluid Volume

Outcomes The client will: Be free of injury Demonstrate increased orientation and reality contact Maintain an adequate balance of activity and rest Maintain adequate nutrition and fluid balance Return to optimal level of functioning (predelirium)

Intervention Promoting safety Managing confusion Promoting sleep and nutrition

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Evaluation Client and family education necessary to prevent recurrence (see transparency) Community-Based Care: Delirium Referral may be necessary for community-based care or rehabilitation if client has lingering cognitive problems resulting from the medical condition. Dementia Dementia involves multiple cognitive deficits, primarily memory impairment, and at least one of the following: aphasia, apraxia, agnosia, or disturbance in executive functioning. Dementia is progressive unless the underlying cause is treatable, such as vascular dementia, which is rare. Clinical Course Mild (excessive forgetfulness, difficulty finding words, loses objects, anxiety about loss of cognitive abilities) Moderate (confusion, progressive memory loss, cant do complex tasks, oriented to person and place, recognizes familiar people; by the end of this stage, requires assistance and supervision) Severe (personality and emotional changes, delusional, wanders at night, forgets names of spouse and children, requires assistance with ADLs) Etiology Various causes, but clinical picture similar for all: Alzheimers disease

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Vascular dementia (may have sudden onset; progression may be Picks disease Creutzfeldt-Jakob disease Dementia due to HIV Parkinsons disease Huntingtons disease Dementia due to head trauma

arrested with treatment)

Cultural Considerations Take into account whether or not client would be expected to know certain information, such as names of past presidents. Recognize differing beliefs about elders.

Treatment and Prognosis Underlying cause, as in vascular dementia, is treated to prevent further deterioration. Medications such as tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) (stops progression for 24 months only) can be used to slow progression. Symptomatic treatment of behaviors such as delusions, hallucinations, outbursts, labile moods, which vary among clients Application of the Nursing Process: Dementia Assessment May need to assess in small increments of time Obtain information from family and records depending on clients cognitive abilities

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General appearance: aphasia, perseveration, slurring, eventual loss of language Motor behavior: apraxia, cannot imitate demonstrated tasks finally gait disturbance, making unassisted ambulation unsafe, then impossible May demonstrate uninhibited behavior: inappropriate jokes, sexual comments, undressing in public, profanity; familiarity with strangers Mood and affect: initially anxious and fearful over lost abilities, labile moods, emotional outbursts, catastrophic emotional responses; verbal or physical aggression possible; may become emotionally listless, apathetic, withdrawn

Thought

processes

and content:

initially

loses

ability

to

think

abstractly, so cannot plan, sequence, monitor, initiate, or stop complex behavior; cannot solve problems; cannot generalize knowledge from one situation to another. Later, delusions of persecution are common. Sensorium and intellectual processes: initially memory deficits that worsen over time, confabulation to fill in memory gaps, agnosia, cannot write or draw simple objects; ability to concentrate or pay attention deteriorates until unable to do either; chronic confusion, disorientation (eventually even to person); visual hallucinations common Judgment and insight: initially recognizes he or she is losing abilities, then insight fades altogether; judgment impaired due to cognitive deficits; worsens over time; client at risk for wandering, getting lost, injuring self, unable to perceive harm Self-concept: initially client is frustrated at losing things or forgetting, sad about getting old; sense of self deteriorates until client doesnt recognize own reflection in mirror Roles and relationships: can no longer work, cannot fulfill roles at home, cannot attend social events, eventually confined to home. Family often become caregivers but feel loved one has become a stranger.

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Physiologic and self-care considerations: disturbances in sleep/wake cycle, ignoring body cues to eat, drink, urinate, etc.; loss of abilities to do personal hygiene, even feeding self

Data Analysis Nursing diagnoses include: Risk for Injury Disturbed Sleep Pattern Risk for Deficient Fluid Volume Risk for Imbalanced Nutrition Chronic Confusion Impaired Environmental Interpretation Syndrome Impaired Memory Impaired Socialization Impaired Verbal Communication Ineffective Role Performance

Outcomes Outcomes for clients with dementia differ from other clients because of the progressive deterioration. The client will: Be free of injury Maintain an adequate balance of activity and rest, nutrition, hydration, Function as independently as possible, given his or her limitations Feel respected and supported Remain involved in his or her surroundings Interact with others

and elimination

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Intervention Interventions are organized around a psychosocial model of dementia care and include: Promoting safety Promoting adequate sleep, hygiene, activity; proper nutrition Structuring the environment and routine Providing emotional support Promoting interaction and involvement (reminiscence, distraction, time

away, going along) Evaluation Ongoing evaluation is necessary to revise plan of care as clients abilities diminish. Community-Based Care: Dementia Many persons with dementia are in the community for most of their lives: Family homes Adult day care centers Residential facilities Specialized Alzheimers units

Role of the Caregiver Most caregivers are women (72%), either daughters (29%) or wives (23%). Caregivers need: Education about dementia and care needed by client Help dealing with own feelings of loss Respite to care for own needs Support groups Assistance from agencies

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Role strain in caregivers is common because of too many conflicting demands and expectations (including expectations they have of themselves ). Use of drugs and alcohol is common. Caregivers may feel unappreciated and may become socially isolated and unwilling to accept help from others. Without intervention, role strain may lead to neglect or abuse. Related Disorders Amnestic disorder Korsakoffs Syndrome

Self-Awareness Issues Inability to teach a client with dementia Feelings of frustration or hopelessness Knowledge that there is progressive deterioration until death, with no hope for improvement

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