Cognitive disorders

Delirium
Disturbance of consciousness accompanied by change in cognition; disoriented
o Alert and oriented to person only
o Typically have problems recalling on memory and time.
Develops over a short period of time
Easily distracted
Difficulty concentrating
Illusions, hallucinations
Onset is rapid
Brief duration
Level of consciousness is impaired
Slurred speech
Anxious mood

Causes of Delirium
Metabolic
InfectionUTI
Low sodium
o Normal is 135-145 mEq/L

o Always check electrolytes!

Drug related
o Or, withdrawal from drugs and alcohol
o Sedatives and benzodiazepines cause confusion
Effects of anesthesia

The nursing process: Assessment

Interview with simple questions and explanations
Frequent breaks
History of onset; not reliable from client
o Interview family members; ask: Is the how your mom typically acts?
Mood/Affect
o Frequently assess moods; moods change quickly
Thought process/content
o Many have visual hallucinations
o Very restless; hard to keep in bed.

Nursing process: Goals

Free from injury
o Fall precautions
Demonstrate increased orientation

o Use reality orientation and validate feelings

Adequate balance of activity and rest
o Help the patient keep days and nights straight
Adequate nutrition
o Often forget to eat; needs nutritional supplements
Return to optimal level of functioning
A goal needs a timeline to make it measurable!

Nursing process: Intervention

Patient safety
Managing confusion
o Often frightened at night.
Promote comfort and rest
Adequate fluids and nutrition
o Always offer little sips of water!

Nursing process: Evaluation

Successful treatment of underlying causes for delirium returns client to former
level of functioning
Client and family education about avoidance of recurrence
Monitor chronic health problems
Careful use of medications

 No alcohol or other non-prescribed drugs

Dementia

Dementia
More progressive, gradual, and permanent
Involves multiple cognitive deficits
o Primarily memory impairment
Involves at least one of the following:
o Asphasia (deterioration of language function)
o Apraxia (impaired ability to execute motor functions)
o Agnosia (inability to name or recognize objects)
o Disturbance in executive functioning (ability to think abstractly and to plan,
initiate, sequence, monitor, and stop complex behavior)
May also present:
o Echolalia (echoing what is heard)
o Palilalia (repeating words or sounds over and over)

Clinical course of Dementia

Mild:
o Forgetfulness

o Difficulty finding words

o Frequently loses objects and experiences anxiety about these losses.
o Occupational and social settings are less enjoyable, and the person may
avoid them.
Moderate:
o Confusion is present along with memory loss
o The person cannot complete complex tasks but remains oriented to
person and place.
o Still recognizes familiar people.
o Some assistance with care
o Executive functioning suffers (especially with ADLs)
Severe:
o Personality and emotional changes occur
o May be delusional, wander at night, forget the names of spouse and
children and require assistance in ADLs.
o Most live in ECF.

Causes of Dementia
Decreased metabolic activity
Genetic component
Infection
Alzheimers disease (#1)

 Creutzfeld-Jacob disease (CNS disorder; develops at 40-60 years. Causes by

infectious particle that is resistant to boiling)
Parkinsons disease
Huntingtons disease (inherited gene; brain atrophy, demyelination, and
enlargement of the brain ventricles. Begins in late 30s)
Vascular Dementia (#2)
o Symptoms similar to Alzheimers, but more abrupt, followed by rapid
changes in functioning; a plateau; more abrupt changes, another plateau,
and so on.
o Caused by decreased blood supply to the brain.

Culture
Native Americans and Eastern countries hold elders in a position of authority,
respect, power, and decision making for family; this does not change despite
memory loss or confusion.
May feel they are being disrespectful and reluctant to make decisions or plans for
elders with dementia.

Treatment for Dementia

Underlying cause
o Example: Vascular dementia can be helped by diet, exercise, control of
hypertension or diabetes.
Psychopharmacology
o Cognex and Aricept are cholinesterase inhibitors and have shown
therapeutic effects; slow the progress of dementia. They do not reverse
damage already done.

 Must have liver function tests done with Cognex.

Flu-like symptoms, diarrhea, sleep disturbances are common.
o Tegretol and Depakote help stabilize mood and diminish aggressive
outbursts.
These doses are often -2/3 less lower than prescribed for
seizures, therefore, does not need to be in the therapeutic level
for blood work.
o Benzodiazepines may cause delirium and can worsen already
compromised cognitive abilities.

Nursing process: Assessment

History
o Remember, interview family
Motor behavior and general appearance
o Display aphasia
o Conversation repetitive
o Apraxia (such as combing hair)
o Gait disturbance
o Uninhibited behavior; never have displayed these behaviors before.
Mood and Affect
o Grieve at first
o Emotional outbursts are common
o Pattern of withdrawal; lethargic, apathetic, look dazed and listless.

 Thought process and content

o Executive functioning impaired
o Have to stop working
o Client may accuse others of stealing lost objects
Sensorium and Intellectual Processes
o First affects recent and immediate memory, eventually impairs the ability to
recognize family members and oneself.
o Confabulation: clients make up answers to fill in memory gaps; often
inappropriate words or fabricated ideas (SCREW YOU, ASSHOLE).
o Visual hallucinations are common.
Judgment and insight
o Underestimate risk
Self concept
o Initially grieve, and then slowly lose sense of self.
Roles and Relationships
Physiologic and self-care considerations
o Altered sleep-wake cycle
o Some clients ignore internal cues such as hunger or thirst
o Neglect bathing and grooming; become incontinent.

Read the Nursing Diagnoses and Nursing Goals on your own. Too damn lazy to
type out.

Nursing Process: Interventions

Demonstrate caring attitude
Keep clients involved; relate to environment
Validate clients feelings of dignity
Offer limited choices
Reframing (offering alternate points of view to explain events)
See page 487theres a good table there about interventions.
SAFETY!
o Physical and Chemical restraint should be the last option

Nursing process: Evaluation

Goals change as disease progresses
Reassessment is vital!
Client always needs assessed, goals and interventions constantly revised
Evaluation is a continuing process.
Remember short term goals; all goals need a time frame.